Failure to Verify Wanderguard Placement Led to Resident Elopement
Penalty
Summary
Staff failed to ensure adequate supervision and monitoring for a resident with a history of cerebral infarction and type 2 diabetes mellitus by not verifying the placement and functioning of the resident's Wanderguard device every shift, as required by physician order and facility policy. The Wanderguard is a monitoring device intended to alert staff if a resident at risk for elopement attempts to leave a designated area. Medical record reviews and staff interviews confirmed that there was no documentation of the required checks, and staff did not follow the established procedures for the Wanderguard system. As a result of this failure, the resident was able to leave the facility without staff knowledge. The incident was discovered only after the resident contacted his mother from outside the facility, prompting the facility to initiate an elopement code and search for the resident. The resident was eventually returned to the facility by his mother. Multiple staff, including the Sub-acute Director, a licensed nurse, the Administrator, and the Director of Nursing, confirmed that the required checks were not performed or documented, placing the resident at risk for elopement.