- Date
- 2/11/2024
- Report number
- 00312463-AP-264898
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- The facility failed to provide appropriate supervision to the Alleged Victim (AV) according to his/her care needs. AV is care planned for mild to moderate disorientation and displays deficits in judgement. AV has a known history of wandering and exit seeking. On February 11, 2024, AV eloped from a secure unit twice; first incident occurred at 3 am and second incident occurred shortly after the first incident around 4:46am. The first incident, AV exited the facility without an escort and was found by assisted living staff who brought AV back to the memory care unit. The second incident, AV exited the facility without an escort after being toileted and shortly after the first incident and was found by maintenance workers who escorted AV back to the memory care unit. At time of incident, the weather forecast was rain with outside temperature around 44 degrees. Based on facility documentation and interviews, AV exited the memory care through a malfunctioning door. The facility's failure resulted in AV eloping the secured building, without staff knowledge, placing him/her at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00630 $1125.00 fine assessed