complaint·May 15, 2024

One night prior to R1’s elopement from the facility, R1 had a fall in the facility causing head trauma and requiring R1 to be observed in the hospital overnight. R1 sustained a hematoma and concussion from the fall. The hospital cleared R1 to leave the next day; and R1 was brought back to the facility the day of the elopement. According to the allegation, the facility was informed of the injury and stated that R1 would be properly supervised, including additional supervision due to the head injury from the fall. However, this supervision did not occur and R1 eloped from the facility due to improper supervision. On 04/11/2024, Licensing Program Analyst (LPA) Brian Phillips conducted a complaint investigation visit to the facility above. During this visit, the LPA toured the physical plant areas inside and outside that included the observation of the common areas of the facility as well as the individual resident bedroom areas of the facility. LPA observed that most resident bedrooms in the facility contain a front bedroom door as well as a separate door/sliding door to the exterior of the facility. The doors exiting the interior of the facility are monitored by an auditory alarm system in place that alerts Staff members with a loud noise when a door exiting the facility has been opened. These auditory alarm system(s) are located on every door that exits the interior of the facility into the outdoor areas/out of the facility. The auditory alarm system(s) consist of an electronic plastic/metal box and/or device approximately the size of a telephone that are attached to each door at eye level. The auditory alarm system(s) are powered by batteries which need to be changed monthly according to Staff interviews by LPA. This auditory alarm system is in place on the front door of the facility which exits the facility into the front yard and street. The bedroom of Resident #1 (R1) did have an auditory alarm system in place attached to the sliding door exiting R1’s bedroom into the backyard at the time of the allegation. On 04/11/2024, during the complaint investigation visit, LPA interviewed Staff members about the auditory alarm system(s) in place on doors exiting the facility to outdoor areas, and the monitoring of residents at night in the facility. According to Staff member interviews, the auditory door alarms/alert systems on each exit door out of the facility are battery powered which need monthly maintenance to change the batteries. Without the changing of batteries in the auditory alarm systems monthly, the noise emitted when an exit door is opened could be very faint or potentially nonexistent. Staff members interviewed by LPA stated that the batteries are changed monthly in the actual auditory alert system situated on each doorway out of the facility. Continued on 9099-C However, the Licensee/Administrator informed LPA that the complaint allegation occurred almost exactly a month after the batteries were changed and that the auditory alarms could have been muffled or faint due to the circumstance of the batteries needing to be replaced at the time of the elopement by R1. The Licensee/Administrator was not present at the time of the elopement by R1 and is the only Staff member that oversees changing the batteries in the auditory alarm system(s) on doors exiting the facility. All Staff members interviewed by LPA denied that Staff members scheduled for overnight supervision of residents clock out or go to sleep on duty. All Staff members interviewed by LPA denied that the facility needs to be "shut down" early at night because of residents with dementia related conditions including sundowning. LPA interviewed Staff members of the facility about the facility response to the incident occurring the night prior to the elopement allegation in which R1 fell and suffered a head injury. LPA was told that after R1 was discharged from the hospital with a bad concussion, Staff were informed and knew that R1 required extra surveillance/monitoring due to the hematoma and concussion in addition to R1’s preexisting medical diagnosis. During interview with LPA, the Licensee/Administrator stated that the batteries in the auditory alarm system may have died/run out of charge causing the auditory alarm to be lowered or nonexistent. Staff members interviewed by LPA denied that the facility was totally dark with no movement inside and no responses to multiple knocks on the front door and ringing of the doorbell when Law Enforcement brought back R1 from the elopement. However, Staff members interviewed by LPA stated that they did not know if the door had been forgotten to be locked or the auditory alarm put on the evening of the elopement by R1. Staff members stated to LPA that sometimes if the battery in the auditory alarm system is low, then the sound of an exit door from the interior of the facility being opened can be very faint. Staff members interviewed by LPA stated that they did not know of any Staff member using their on-duty shift to sleep instead of providing supervision to residents. However, through Staff interviews, LPA learned that several Staff members work/live at the facility in a converted garage/Staff bedroom. LPA asked about the schedule of Staff members living in the converted garage and was told that there are Staff members who work during the morning and daytime so they can sleep at night, as well as Staff members with overnight schedule(s) which involved evening and nighttime supervision of clients. LPA corroborated this information through record review of the facility LIC 500 Personnel Report dated 04/11/2024 which specified the days and hours on duty for each individual Staff member of the facility. According to Staff interviews by LPA, there are employees who live in the converted garage/Staff bedroom with an employment schedule daily from morning until afternoon or early evening. Continued on 9099-C Staff members interviewed by LPA stated that these Staff members could be asleep at night in the Staff bedroom/converted garage and would hear it if a resident attempted to open a door out of the facility because of the auditory alarm system. During the 04/11/2024 complaint investigation visit, LPA requested and received relevant documents from the facility that would be pertinent to the investigation. LPA received the following information/documentation from the facility pertinent to the complaint allegations regarding residents in care: Release of Resident medical information, Identification and Emergency Information, Decisions about medical treatment, physician’s notes for resident, Resident Appraisals, Statements of Patient Advocates or Ombudsman, Physician Orders for Residents including Primary & Secondary diagnosis, Advance Health Care Directives, Appraisal Needs & Services Plans, Physicians Reports for Residential Care Facilities For the Elderly (RCFE), Tuberculosis (TB) Screening Results, Pharmacy Delivery Notes, and Emergency Department Patient Discharge Instructions. LPA received the Centrally Stored Medication and Destruction Record kept by the facility for resident(s) in care. The Physician’s Report for R1 dated 03/15/2023 indicated that R1 had a diagnosis of Dementia with a mental condition that included confusion/disorientation and wandering behavior. However, this Physician’s Report also indicated R1 was able to follow directions and was not able to leave the facility unassisted/without assistance. R1’s Preplacement Appraisal Information dated 03/21/2023 indicated a mental condition of mild Dementia but was able to walk without any physical assistance and was labeled as non-Ambulatory due to Dementia limitations. The facility kept a document which detailed the daily care/services for R1. On this document there is a section labeled “Overnight Shift” which states that R1 needs bedtime medications at 8:00pm and usually goes to bed around 9:30pm-10:00pm. According to the complaint allegation as well as the Law Enforcement report from the elopement of R1, the neighbor called Law Enforcement at approximately 7:00pm at night after seeing R1 sitting on their lawn. Based on the information obtained, there was Sufficient evidence to prove the allegation. Therefore, the allegation is deemed Substantiated at this time. Exit interview conducted, a copy of this report was provided to the facility.