Failure to Provide Adequate Supervision and Thorough Search Following WanderGuard Alert
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision and a thorough search in response to a WanderGuard alert for a resident with severe cognitive impairment and a high risk for elopement. The resident, who had diagnoses including Alzheimer's disease, dementia, and a history of wandering, was wearing a WanderGuard bracelet and was known to be independent with ambulation but required assistance with activities of daily living. On the day of the incident, the resident triggered the WanderGuard alarm by exiting through a stairwell door, but staff did not immediately open the door to search the staircase where the alert sounded. Camera footage and staff interviews revealed that although staff responded to the alarm within 36 seconds, they did not check the stairwell immediately and instead began searching other areas. The resident was able to exit the building through the stairwell, walk around the sidewalk at the back of the facility, and was eventually found on the ground near the parking lot approximately five to six minutes later. The resident sustained visible injuries, including a forehead abrasion and right ankle swelling, and was transported to the hospital for evaluation and treatment. The facility's policy required prompt and thorough investigation when a resident could not be located, but staff actions did not align with this expectation. Staff interviews indicated confusion about the alarm system and the appropriate response, with some staff not understanding the alarm codes or the need to open the door to the stairwell immediately. The failure to provide adequate supervision and to implement a thorough search in response to the WanderGuard alert resulted in the resident's elopement and injury, constituting immediate jeopardy.