1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25 | Licensing Program Analyst Ryker Heberle (LPA) arrived at the facility unannounced to conduct a case management visit regarding an incident of elopement by a resident (R1) from the facility. LPA met with facility Administrator Sam Faye (Admin).
Admin was able to determine that at around 6:00pm-6:30pm, paramedics and firefighters arrived at the facility to assist a different resident in receiving medical care and being transported to the hospital. Admin believes that while the paramedics were entering and exiting the facility, the resident slipped out beyond the delayed egress doors. R1 was then discovered to be missing at 10:00pm. R1 was brought back to the facility by family at 2:00am the following morning.
Review of the egress door records by the administrator indicate that there was no instance of the egress alarm being triggered at the date and time of the incident, and noted that entry and exit through use of a code would not log an incident in the report. LPA tested the delayed egress doors and observed them to be functioning properly. Review of facility exterior camera footage showed the resident leaving the facility through the side door at 6:06pm. R1 was not observed by facility staff between the hours of 06:00pm and 2:00am, No staff observed the elopement. Review of R1's care plan indicates that R1 requires visual check in two times per shift. It is undetermined when the two evening shift check-ins occurred on the day of the incident.
Deficiency cited. See 809-D. This report was reviewed with facility Administrator Sam Faye and a copy of the signed report was provided. |