Incident investigation·December 5, 2022

On 12/5/2022, Licensing Program Analyst (LPA), Murial Han conducted an unannounced case management visit to follow up on an incident that was reported by the facility. On 11/4/2022, facility reported resident #1 (R1) eloped through the delayed egress door, took stairwell and was found by staff on the 5th floor roof top. On 11/7/2022, the assistant administrator stated that R1 resides in the 3rd floor memory care unit and exited through the delayed egress door which triggered the alarm and subsequently the over head paging system announcing that the delayed egress door was opened. Staff witnessed the door opened which triggered a head-count and discovered R1 was missing. Staff started searching, and found R1 on the 5th floor roof and escorted R1 back to the unit. The assistant administrator also stated that the delayed egress door is 30 seconds delayed. On 11/7/2022, LPA inquired about staff response time after the alarm went off as the delayed egress door is 30 seconds delayed to prevent elopement while maintaining life safety. The administrator stated that during the incident, the delayed egress door was malfunctioned, therefore, the door opened right away and staff did not check the stairwell that is outside of the door. In addition, the administrator stated that the delayed egress door was routinely checked but there was no documentation provided of such checks. However, since the incident, the door was repaired and during the repair, a staff was assigned 24 hours a day to monitor the door/exit until it was fixed. In addition, the facility started to document the preventive maintenance checks twice a day. During today visit, LPA and the administrator checked the delay egress door which was properly functioning and staff responded to the alarm appropriately. In addition, administrator provided documentation of staff monitoring the delayed egress door and staff in-service sign-in records. Based on interview, and record review during the course of the investigation, the facility was not able to proof that the delayed egress door was in good repair and staff did not check the stairwell after the door was opened. Deficiency cited today under California Code of Regulations, Title 22, Division 6, Chapter 8 follows on LIC 809D. If cited deficiency is not corrected by the due date, a civil penalty may be assessed. This report was reviewed and discussed with administrator. Appeals Rights were given. A copy of report was provided.