Incident investigation·July 26, 2024

On 07/26/2024, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced case management-Incident visit. LPA met with Administrator Eric Terrill and announced the purpose of the visit. The Licensing Agency received Incident Reports from the Licensee dated 06/12/2024, 06/19/2024, and 07/14/2024 regarding three (3) elopements from the facility within an approximately one (1) month period by Resident #1 (R1) in which the following was stated to have occurred: On 06/12/2024, R1 eloped from the facility through the front door of the Memory Care Unit. Facility Staff responded immediately and R1 was redirected back into the facility. R1 appeared agitated and PRN medications were administered upon return to the facility. On 06/19/2024, R1 again eloped from the facility and Staff were notified due to a wandering transmitter alert at the Memory Care Unit courtyard fence. Staff were unable to locate R1 at the time of elopement at 12:32am and subsequently called 911 as well as filed a missing persons report with Law Enforcement. R1 was found at 12:57am by Law Enforcement with a laceration on their forehead and transported to the hospital Emergency Room (ER). R1 was returned to the facility with a follow up treatment plan to have an assessment of the PRN medication for R1 by R1’s primary care physician (PCP) and facility Staff to increase additional supervision of R1. On 07/14/2024, R1 again eloped from the Memory Care Unit of the facility. Staff responded to the functional alarm system alert at the Memory Care Unit gate, but R1 was already on the front lawn of the facility by the time staff arrived. R1 was redirected back into the Memory Care Unit of the facility, and both the relative of R1 as well as the PCP for R1 were notified. This incident report indicates that the care plan for R1 has been updated to reflect the wandering and elopement behaviors. A citation and civil penalty is issued for repeated elopements from R1 on 6/12/2024, 6/19/2024, and 7/14/2024. The 6/19/2024 elopement caused injury to R1 and law enforcement response to missing persons report, which posed an immediate health and safety risk to residents in care. Exit interview conducted. A copy of the report was issued to the facility.