Incident investigation·September 13, 2023

On September 13, 2023, Licensing Program Analyst (LPA), Murial Han conducted an announced case management visit to follow up on an incident that was reported by the facility. LPA met with administrator and explained the purpose of today's visit. On September 7, 2023, facility reported to CCL that resident #1 (R1)'s responsible party reported to the facility that on September 1, 2023, R1 left the facility, went for a walked and returned. Facility staff reviewed the video footage and discovered that R1 exited the facility through the back elevator, and returned within 15 minutes. During today's visit, LPA toured the route of how R1 exited the facility, interviewed R1 and the responsible party, administrator, resident service director and resident service coordinator. Based on the incident report, it was indicated that R1 has diagnosis of dementia and is unable to leave the facility unassisted. However, based on R1's physician's report dated on May 10, 2023, R1 was not at risk for leaving the community unsupervised and this was verified in the presence of the administrator. According to R1, he/she took the elevator down, got off in the garage, pressed the button to open the garage door, and left. R1 stated that he/she was not lost, not scared, walked around the facility and returned in a few minutes. As part of R1's service plan, facility will continue to check on R1 every 2 hrs. No deficiency cited today. This report is reviewed and discussed with the administrator. A copy is provided.