Failure to Ensure Safety of Residents at Risk for Elopement
Penalty
Summary
The facility failed to ensure the safety and security of seven residents identified as high risk for wandering and/or elopement. The Touchpad Exit Controller (TEC) system, which is supposed to alarm when a resident wearing a Wanderguard passes through an exit, did not function properly, allowing a resident to elope undetected. This resident was later found across the street with his wheelchair stuck in a sidewalk crack. The facility's monitoring check-off log for the TEC system and exit door alarms was incomplete, missing documentation for certain days and not including all exit doors. The TEC system on one of the exit doors was found to be non-functional during a surveyor's test, and the facility's policy for checking Wanderguard functionality was not followed. The policy required checks every shift, but the orders for residents only required daily checks. Additionally, staff members were not using the available tool to test the functionality of the Wanderguards, relying instead on less effective methods such as placing residents near exit doors to see if alarms would sound. The facility's lack of oversight and failure to ensure that their TEC and Wanderguard systems were fully operational resulted in a resident eloping and endangered the safety of other residents known to wander. Interviews with staff revealed that the TEC system was not properly maintained, with issues such as missing screws and unplugged components, contributing to the failure of the system to alarm as intended.
Plan Of Correction
Accidents and Hazards How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The resident identified experienced no adverse effects and does not recall the incident. The resident was moved to a new room on 2/26/25, further from an exit door with no new incident noted. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: Any resident who has been identified as an elopement risk had the potential to be affected. No other residents were affected. 1. On 2/25/25, the nurse on duty addressed the loose wire on the identified door. Maintenance conducted an assessment on 2/26/25 and secured the wiring further. Additionally, on 2/26/25, Maintenance installed a Velcro stop sign on the identified door as a deterrent. A fire alarm box was added to this door on 3/13/25 as an additional safety measure. 2. Maintenance log/audit was updated on 3/13/25 to include all doors and the device that is being checked on each door. 3. The TEC system on station 3 door is working but showing a slight delay when alarming. TEC systems have been contacted to address the need for increased sensitivity. Additionally, this door includes a locked alarm box that alarms, and the Wanderguard sensor was an additional backup alarm. 4. Wanderguard Process Guide was edited to match the physician orders. 5. On 3/12/25, nurses identified as not knowing how to check the Wanderguard functionality were in serviced by the nurse manager. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not reoccur: On 3/17/25, the Administrator provided in-service training to the Director of Maintenance during the routine inspection of doors equipped with Wanderguard sensors. The inspection will now also include checks for loose wiring and whether the sensor is secure. On 3/17/25, the Nurse Manager initiated in-service training for licensed nurses on the proper method to check the functionality of the Wanderguard system for their residents. Maintenance will complete a daily audit (Monday through Friday) of the exit doors alarm systems including Wanderguard system and/or Red Fire Box. This audit will include a review for potential loose wires, Wanderguard sensor and functionality, and Red Fire Box sensor and functionality. Medical Records will check weekly that the Wanderguard orders match the policy. The Director of Nursing (or designee) will audit two nurses weekly to ensure they can correctly verbalize the process for checking a resident's Wanderguard functionality. How the facility plans to monitor its performance to make sure that the solutions are sustained: Results of the audit will be brought to the Quality Assurance Performance Improvement (QAPI) monthly. If 95% compliance is met after 90 days, QAPI will be resolved. Include dates when corrective action will be completed: Corrective action for deficient practice will be completed by March 18th, 2025.