Failure to Maintain Wanderguard System and Comprehensive Elopement Risk Assessment
Penalty
Summary
The facility failed to maintain a functioning Wanderguard system and did not comprehensively assess or implement appropriate interventions for residents at risk of elopement, resulting in two residents successfully eloping from the building. In one case, a resident with severe cognitive impairment and a history of wandering was able to exit the facility without the Wanderguard alarm sounding. Staff did not notify maintenance of the malfunction, did not test all doors or Wanderguard devices after the incident, and did not provide education to staff regarding system testing. The Director of Nursing was unaware of manufacturer recommendations for testing and did not know how the doors were being tested. Another resident, with multiple diagnoses including dementia, Parkinson's disease, and visual deficits, was not accurately assessed for elopement risk despite documented behaviors such as confusion, wandering at night, and exit-seeking. The resident exhibited multiple behaviors and verbalizations indicating risk, including calling 911, wandering the facility at night, and expressing a desire to leave. Despite these behaviors, the resident was not reassessed for elopement risk, and no interventions beyond the eventual placement of a Wanderguard were implemented. The care plan did not specify the needed level of supervision or address the management of elopement risk factors. Testing of the Wanderguard system revealed that four out of five doors did not alarm when tested with a Wanderguard bracelet, and one door did not alarm when opened with the automatic button. Staff and the Environmental Services Director were unaware of these issues, and daily testing logs were found to be incomplete. The administrator and staff relied on the Wanderguard system to alert them to elopement risks, but the system's failure left residents unsupervised and able to exit the facility undetected.