Reflections at the Oasis.

“Based on observation and interview, the governing authority failed to ensure the health, safety, or welfare of a resident was not placed at risk of harm for one of ten residents. The deficient practice posed a risk as the facility was unaware of the general or specific whereabouts of a resident and the resident eloped from the facility. Although there was no negative outcome, the resident was placed at risk of harm. Findings include: 1. At the entrance of the gated premises, this Compliance Officer observed a security booth staffed with a security guard. Anyone entering the premises had to check in with the security guard to report the reason for entering. Anyone exiting could do so freely, however, they would still have to pass by the security booth. 2. While on-site, this Compliance Officer observed the door in the dining hall that R1 allegedly exited the facility from. As there were no cameras in the dining hall it could not be confirmed if R1 exited the facility from the door in the dining hall or the door in the kitchen. However, the door alarm in the dining hall had been activated which indicated the likelihood of R1 exiting from that door. Regardless, either of the two doors (dining hall door or kitchen door) provided access to an area that was not completely secure and allowed for individuals to access the entire campus area. 3. In an interview, E1 explained the incident occurred during the dinner transition, in which R1 had come into the dining area and must have exited out the back door of the dining room while the caregivers were retrieving the other residents from their rooms. Although the door alarm was activated there was a miscommunication with the kitchen staff in turning the door alarm off without realizing the reason the alarm had been triggered. The kitchen staff believed that a caregiver had caused the alarm to go off as that had happened in the past. Therefore, staff did not realize R1 was missing until all of the residents had all sat down for dinner at 4:50 PM. That gave R1 time to walk to the main gate and exit the facility, at which point the security guard should have acted as a fail-safe measure but didn't. E1 reported that as soon as staff realized R1 was missing, the security team and management team were notified. 911 and R1's family were both notified and staff joined in the search for R1. R1 was located at 6:42 PM by a staff member sitting on a rock next to an apartment complex near 19th Avenue and Cactus. 4. In an interview, E1 acknowledged that while R1 was not harmed and overall there was not a negative outcome, R1 had still been placed at risk of harm. E1 explained that an elopement drill was conducted with all staff the following day; an alert was added to the kitchen door even though only staff should have access to that door; the delays were changed on the kitchen doors so staff no longer had to badge out; and a camera was installed in the dining area.”