Incident investigation·May 5, 2021

Licensing Program Analysts (LPAs) Ashley Smith and Sandra Urena conducted an unannounced Case Management - Incident visit at the facility today to follow up on an incident pertaining to Resident #1 (R1). The LPA met with Executive Director Ronda Wilkin and explained the reason for the visit. On 4/26/2021, the LPA received a call from the Executive Director, whom reported an elopement. On 4/25/2021 at approximately 7:47 p.m., R1 exited from the rear of the community though a service door. R1 walked the perimeter of the community and at approximately 8:56 p.m., R1 knocked on the front door and re-entered the community. Staff were unaware that R1 was out of the community. A body assessment was conducted, and no injuries were noted on R1. Per interviews and video survelliance review, R1 walked around the perimeter of the community for 80 minutes. The facility is equipped with Wanderguard, yet R1 does not wear a Wanderguard. Prior to the on-site visit, this community submitted an incident report, the staff schedule for the evening of 4/25/2021, and the community’s elopement protocols. During today’s visit, the LPAs spoke with the Executive Director, obtained copies of R1’s physician’s report, appraisal and staff training materials, and conducted an exterior physical plant tour at 10:50 a.m. Based on interview and record review, the facility does status checks of residents every two hours. Hence, the resident could have left after a successful status check. In addition, staffing was sufficient at the time of the incident. Yet, the Administrator confirmed that the egress connection for the service door was inoperable at the time of the incident. Thus, that is why R1 was able to egress without triggering an alarm. It is unknown as to how long the egress for the service exit was inoperable prior to R1 exiting on 4/25/2021, as any resident could have used this door without triggering an alarm. However, the egress connection was repaired on 4/26/2021. The egress was operable at the time of today’s visit. After this incident, an in-service training on Elopement Protocols and Procedures was held. Copies of the training documents were obtained. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, today's report and appeal rights were reviewed and issued.