Resident Elopement Due to Inadequate Wanderguard Coverage and Lack of Care Plan
Penalty
Summary
A resident with diagnoses of Alzheimer's Disease and dementia, and documented severe cognitive impairment, was admitted to the facility and wore a Wanderguard monitor bracelet. Despite this, the resident was able to elope from the facility premises. The resident was found sitting on a sidewalk three houses down from the facility. Review of the resident's records showed that there was no documented evidence of a person-centered care plan addressing the risk of elopement prior to the incident, despite the resident's known cognitive impairments and risk factors. Further investigation revealed that although the resident was wearing a Wanderguard bracelet, the North-north exit door used by the resident to leave the facility did not have a Wanderguard system sensor installed. The Director of Nursing confirmed that the purpose of the Wanderguard system is to alert staff when a resident at risk for wandering approaches or exits through a monitored door, but this system was not in place on the door used during the elopement. Facility policy required adequate supervision and care planning for residents at risk of elopement, which was not implemented prior to the incident.