Incident investigation·August 13, 2024

At approximately 1:00pm LPA Christi Coppo and arrived unannounced to conduct a case management regarding Incident Report received on 8/9/2024. On 8/9/2024 facility submitted to CCL Incident Report indicating resident (R1) had eloped. R1 has a diagnosis of dementia and resides in Memory Care. R1 had been recently moved from AL to Memory Care and was experiencing some confusion. On 8/8/2024 resident had been experiencing some restlessness and stopped to rest in a chair outside another resident's room. R1 had fallen asleep in the chair; rather than wake R1, staff let them rest and checked on them as staff performed their shift duties. At approximately 3:15am, NOC caregiver (S1) noticed that the resident was no longer in the chair. S1 went to check R1's bedroom to make sure they weren't in their room. S1 then alerted Resident Care Coordinator (RCC) (S2) that R1 was unaccounted for. RCC then notified Health and Wellness Director (HWD). While performing checks and searching, police notified the facility that R1 had been located and that an officer was with R1 at a nearby gas station. NOC Med Tech (S3) retrieved R1 from police and escorted them back to the facility. At approximately 3:30am, R1 returned to the facility. HWD performed a thorough head to toe examination of R1 and found resident to be sleepy, but without injury. R1's care plan was updated and increased safety checks were performed every 30 minutes. All required parties were notified. Upon R1's return, facility immediately conducted investigation of elopement. Investigation found that the north egress door had not latched completely after staff had exited, so the alarm was not engaged. This is the reason for the alarm not sounding when R1 opened it. Maintenance director and Admin conducted staff training and performed an elopement drill which included a demonstration of facility egress doors and alarms. Procedures for locating and searching for residents were also part of the drill. Training log and drill attendance form provided to LPA at time of case management. Additionally, facility implemented census check and egress door check as part of shift change procedures; checks are completed every shift change. Continued on 809C... Continued from 809... Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given .