Failure to Prevent Elopement Due to Inadequate Supervision and Wanderguard Monitoring
Penalty
Summary
A resident with diagnoses including COPD, cachexia, panic disorder, depression, dementia, and mild cognitive impairment, and who was assessed as having severely impaired cognition, eloped from the facility for an extended period. The resident was identified as being at risk for exit seeking and elopement, with interventions in place such as a wanderguard device attached to her wheelchair, regular checks of the device, and supervision as needed. Despite these interventions, documentation showed that on the day of the incident, the day shift did not mark that the wanderguard was in place, and the resident was last seen at 9:00 A.M. by staff. The resident was later found at a local store by police, having been missing for several hours, and her wanderguard was not in place when she was located. Interviews with staff revealed that multiple CNAs and a medication technician had seen the resident earlier in the day, but no one had direct knowledge of her whereabouts after the morning. Staff assumed the resident was in her usual locations within the facility, such as the dining room or activity areas, and did not verify her presence during lunch when her tray was left untouched. The facility did not have cameras near the front door, and staff did not initiate a headcount when first notified by the store about a woman in a wheelchair, as they did not immediately recognize the resident was missing. The resident had a history of removing her wanderguard, but staff believed the device had been effective since it was moved to her wheelchair. The facility's elopement policy required rounds at specific times and procedures for missing residents, but these were not followed effectively on the day of the incident. Staff did not perform timely checks or a headcount, and the absence of the resident went unnoticed for several hours. The resident was ultimately found safe, but the failure to ensure the wanderguard was in place and to provide adequate supervision led to the elopement event.