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25 | Licensing Program Analyst (LPA) Sabrina Calzada arrived to conduct a case management inspection related to a recent incident report submitted for resident (R1), who is conserved. LPA met Karen Padilla, Director of Nursing (DON) and stated the reason for today's inspection.
LPA and DON discussed a recent incident where resident (R1), who resided in the Assisted Living portion of the community, was able to leave the facility unassisted, on 7/6/24, Saturday, around 1:30 pm. When (R1) was discovered missing, (4) staff members immediately went outside to look for him, and the Assistant Administrator was notified, who contacted the police, also at that time (1:45 pm). The police promptly informed the facility that they found (R1) four blocks away from the community, and resident was being taken to the hospital for an evaluation, in part due to the extreme outside temperatures that day. (R1) returned to the community with the Co-Administrator, from the hospital around 9:00 pm, and without having sustained any injuries. (R1's) care plan is being updated at this time and a new doctor is being sought for (R1), when an updated physician's report also be obtained.
LPA and DON reviewed (R1's) most recent physician's report which does not indicate a diagnosis of Dementia; however, notes that resident is not permitted to leave the facility unassisted. The report does not state that (R1) has any elopement tendencies, and this is not noted on the Pre-Appraisal Assessment either.
The Pre-Assessment states that resident can walk short distances; however, (R1) moved in using a wheelchair and continued to use it. DON stated that (R1) was able to leave the facility, on foot, which was not expected by staff, and staff are continually monitoring the front reception desk and lobby area. The incident report was submitted to the Department, on 7/10/24, along with a statement from the Assistant Administrator summarizing the information on the incident report.
There are no deficiencies issued on this report. The facility promptly followed their missing person protocol and moved (R1) to the Memory Care Unit.
LPA and DON discussed follow up training and discussions, including but not limited to: staff training with reception staff, review physician's reports and compose a list of which residents cannot leave unassisted, staff elopement training, install a door bell ring camera at the front door,review Regulation 87705. DON agrees to submit documentation of the above by 7/25/24. Exit interview. Copy of report provided. |