Incident investigation·September 30, 2024

On September 30, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit to follow up on an incident that occurred on 9/21/24. LPA met with Activities Director, Nancy Medina and explained the purpose of the visit. On September 24, 2024, Licensee reported that Resident 1 (R1) was found outside along the driveway of the facility. According to the Licensee, a bystander observed R1 climbing the metal gate and was able to get out. Bystander was trying to redirect R1 until staff came out to get R1. Skin abrasions were noted. During the visit today, LPA conducted interviews and reviewed R1's file. According to file reviewed, R1 has a diagnosis of Alzheimer's Dementia and is unable to leave the facility unassisted. LPA did not observe any reappraisal for R1 after R1 eloped on 9/21/24. In addition, during the file review, LPA observed that R1's physician's report is dated from 2/28/23. Facility failed to ensure an updated annual medical assessment/ physician's report is maintained in R1's file. According to the Administrator, R1 used the exit door in the dining room and gained access to the courtyard and climbed up the metal gate. In addition, the administrator was unable to provide information on why the staff didn't hear the auditory alarm when R1 opened the exit door and why staff was unable to respond immediately. Based on staff interviewed, it was indicated that staff were assisting other residents and was unable to respond immediately. During the visit today, LPA opened the exit door in the dining room to ensure alarms were on and functioning. It was observed the alarm was on and in good repair. 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 Activities Director and a copy is provided with appeal rights.