- Date
- 2/28/2025
- Report number
- 00386206-AP-336715
- 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 needs. Based on facility documentation and interviews, AV was admitted to the facility as a new resident on February 25, 2025. Shortly after admissions to the secured memory care facility, AV began showing signs of exit seeking behavior. On February 27, 2025, AV was able to elope from facility by lunging and breaking through the magna-locked emergency door. After AV eloped on February 27, 2025, the facility put in a "maintenance order" to have the door out of which AV eloped checked to ensure it was safe and secure, and facility staff increased safety checks for AV. On February 28, 2025, AV eloped from the facility a second time by the same way. A member of the community alerted facility staff to AV's presence outside of the facility and staff then found AV walking down a high-traffic street and AV appeared confused due to AV's diagnosed cognitive disease and AV was newly admitted resident needing full time care. The facility's failure to provide a safe and secure environment as a memory care endorsed facility resulted in AV eloping from the secured building, without staff knowledge, placing him/her at risk of serious harm due to AV being found walking on a busy street appearing confused, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- RCFCP25-00836 $1125.00 fine assessed