Failure to Ensure Proper Functioning of Wander Management System Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision, monitoring, and safety precautions for a resident with severe cognitive impairment and a high risk for elopement. The resident, who had diagnoses including dementia with behavioral disturbance, anxiety, and a history of falls, was assessed as being at risk for elopement and had a care plan in place that included the use of a HUGS wander alert bracelet. Documentation indicated that the resident exhibited frequent exit-seeking behaviors, required constant supervision, and had a history of attempting to leave the unit. On the day of the incident, the resident's HUGS tag was replaced due to a low battery. During the replacement process, staff failed to properly activate and assign the new tag in the monitoring system. As a result, the resident was not protected by the wander management system, and no alarm was triggered when the resident left the unit. The resident was able to exit the building without staff being alerted, and was later found outside by security personnel. Interviews with staff revealed confusion and lack of clarity regarding the proper procedure for activating and assigning the HUGS tag, as well as inconsistent documentation and verification of the tag's functionality. The failure to ensure the HUGS tag was correctly activated and assigned, combined with the lack of effective supervision and monitoring, directly led to the resident's elopement. The system did not alert staff when the resident left the unit, and the resident was able to leave the building unobserved. The deficiency was further compounded by staff not immediately realizing the resident was missing and only discovering the elopement after a period of time had passed.