Incident investigation·May 12, 2023

Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced case management investigation at the facility. LPA met with facility Administrator Candi Bolin (Admin). Case management was initiated in response to an incident report sent to the department by the facility, which detailed an elopement of a facility resident (R1) that occurred on 02/24/2023. In interview with facility medical director regarding the details of the elopement, it was determined that the facility became aware of the elopement due to a phone call from R1's responsible person (RP). RP stated that R1 was discovered outside of the community by a pedestrian (W1), who was able to make contact with RP due to R1 having RP's contact information on their person. Review of R1's physician's report indicated that R1 is not permitted to leave the facility unattended. RP picked up R1 and returned them to the facility at approximately 04:00pm. The facility was unable to determine when R1 eloped, but believe that it occurred during peak hours of foot traffic in the facility (12:00pm-1:00pm). Facility had two staff monitoring the facility exit, but did not detect R1 leaving the facility. In R1's progress notes, it was not noted what time R1 eloped from the facility, Review of R1's progress notes did not yield any information in reference to R1's elopement. Upon return to the facility, R1 was given a wander guard to detect further elopements. Since elopement on 02/24/2023. R1 has not attempted to elope the facility again. The facility has not had any elopement concerns since elopement on 02/24/2023. Facility is currently in the process of front doors being installed with delayed egress devices to prevent future elopements from the facility. Deficiency has been cited, see 809-D. This report was reviewed with facility Administrator. Advisory notes and signed copy of this report was provided.