Incident investigation·July 18, 2022

On July 18, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident that occurred on July 11, 2022. LPA met with Staffing Coordinator, Maria Miller and Director or Resident and Family Services, Kate Rickard joined shortly thereafter. LPA explained the purpose of the visit. The Licensee reported on July 11, 2022, Resident #1 (R1) was observed by a caregiver (S1) climbing over the facility gate. S1 immediately ran towards R1 and called for help. R1 was already on the other side of the gate by the time S1 got to the gate. R1 was observed outside the community, walking up the hill to the twin pine park. Staff members followed R1 and tried redirecting him/her to the facility, however R1 refused. Medications were administered to R1 and R1 became cooperative and returned back to the community. During the visit, LPA reviewed R1's files and interviewed staff. Files reviewed indicated that R1 has a diagnosis of Alzheimer's Dementia and is unable to leave the facility unassisted. According to the staff interviewed, R1 is a newly admitted resident and has a history of elopement from previous facility. According to R1's file, R1 eloped from a facility by climbing a 10ft wall. The facility notified responsible party and R1's physician. R1's physician adjusted R1's medications and a one on one caregiver was assigned. Deficiency of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page. Report is reviewed with Staffing Coordinator, Maria Miller and Director or Resident and Family Services, Kate Rickard and a copy is provided with appeals rights.