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LPA conducted interviews with Staff #1 (S1), Staff #2 (S2), Resident #2 (R2) and Witness #1 (W1), in regard to staffing needs. Interviews revealed that when the facility would experience a staff call-out, the shift would immediately be covered. Based on the, aforementioned, schedule and interviews conducted, there is not a preponderance of evidence to show whether the allegation did nor did not occur therefore, it is deemed to be unsubstantiated.
It was alleged that the facility failed to report incidents. It was reported that there were several falls that were not reported to CCLD causing concern for the safety of the residents in care. LPA reviewed incident reports received and recorded in the CCLD database from January 2020 through September 2020 which revealed that the facility was reporting incidents on a regular basis. LPA investigated and cross-referenced several of the dates listed in the complaint as non-reported incidents to CCLD and discovered most to have been reported while others were incidents not required for reporting to the department. It was observed that some of the dates of falls listed in the complaint report could not be verified. Based on file review and interviews conducted, there is not a preponderance of evidence to show whether the allegation did nor did not occur therefore, it is deemed to be unsubstantiated.
It was alleged that a resident left the facility unsupervised. It was reported that Resident #1 (R1) had left the facility through a service door and hitchhiked back to R1's family’s home and was missing for over an hour before being found. LPA conducted a virtual tour of the area where R1 had exited the building onto a non-busy street. LPA conducted interviews with S1, S2, S3, Administrator and R1’s family as well as reviewed R1’s physician’s report, assessment and care plan. Interviews and documentation revealed that R1 was high functioning but suffers from Mild Cognitive Impairment (MCI). R1 also had a cell phone with a Lyft application installed giving R1 access to requesting ride services. The applications was installed by R1’s spouse onto both of their phones, prior to R1 moving into the facility, and was used by R1’s spouse to be able to travel to the facility when visiting. Interviews, observations and document review revealed that R1 had become confused and desired to go home. R1 had requested to be picked up by Lyft services at the facility. R1 exited the facility through a delayed egress door, sounding the alarm, and at the exact time that the Lyft service arrived to pick her up. When the staff arrived following R1’s exit, R1 was not seen. An assessment of residents was immediately conducted and R1 was reported to be missing within 10 minutes and R1’s family had been notified.
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