Failure to Maintain Safe Operation of WanderGuard Exit System
Penalty
Summary
The facility failed to maintain the safe operating condition of an exit equipped with the WanderGuard System, which is designed to prevent elopement among residents identified as being at risk. Six residents were identified as elopement risks, and one resident, who was non-ambulatory and required a WanderGuard device on their wheelchair, was observed unattended in the main entrance lobby on multiple occasions. Record review confirmed that this resident was care planned for WanderGuard use and required supervision. Staff interviews revealed a lack of knowledge regarding how to assess the functionality of the WanderGuard system. During a demonstration, the WanderGuard alarm was triggered as the resident's wheelchair approached the main entrance, but the sliding glass doors did not close or lock as intended, allowing the possibility for a resident to exit the building. The DON confirmed that elopement risk residents should be supervised and was unaware that the doors could remain open when the WanderGuard system was activated. The deficiency was further substantiated by direct observation and staff acknowledgment that the system did not function as required to ensure resident safety.