Failure to Prevent Elopement of Cognitively Impaired Resident Due to Monitoring and System Failures
Penalty
Summary
Facility staff failed to adequately monitor a cognitively impaired resident with known exit-seeking behaviors, resulting in the resident leaving the building unsupervised. The resident, who was wheelchair-bound with a right below-knee amputation and a Stage III left heel wound, had previously attempted to elope and was assessed as needing a Wanderguard bracelet. Despite these interventions, the resident was able to exit the facility through the front entrance when the WanderGuard system failed to alarm due to a power surge and a malfunctioning door. Staff did not hear any alarms, and the resident was not located within the facility or on the grounds, prompting notification of local authorities. The resident was found by police several hours later near a highway exit and returned to the facility. Documentation revealed a delay in reporting the incident to the state agency, as well as a lack of wound measurements for the resident in the days following the elopement, with subsequent documentation showing a decline in the wound's condition. Interviews with facility staff indicated uncertainty about the cause of the door malfunction and the effectiveness of the WanderGuard system during power surges. The incident was determined to be Immediate Jeopardy past non-compliance.