Failure to Prevent Resident Elopement Due to Inadequate Supervision and Alarm System Testing
Penalty
Summary
A resident with severe cognitive impairment, anxiety, unsteadiness, and a history of falls was admitted to the facility and later identified as being at risk for wandering due to confusion and impaired safety awareness. The resident's care plan included the use of a wander alert device, which was to be checked each shift and tested nightly. Despite these measures, the resident was able to exit the facility on multiple occasions without staff knowledge, remaining on campus but unsupervised. On one occasion, the resident was observed outside by a staff member, and it was discovered that the wander alert device did not trigger an alarm when the resident exited, although it functioned when the resident returned inside. Interviews with staff revealed that while the wander alert devices worn by residents were checked for functionality, the alarm boxes at the facility doors were not routinely tested to ensure they would sound when a resident with a device approached or exited. Staff also reported that alarms were not always audible from resident rooms, and some staff only became aware of the resident's exit after being informed by others. Documentation showed that the wander alert device was replaced after the incident, but subsequent testing of the original device indicated it was still operational, and the reason for the malfunction during the incident could not be determined. The facility's policy required daily testing and documentation of the wander management alarms, but the investigation found that only the wearable devices were checked, not the door alarm boxes. Additionally, the facility was unable to provide the operation manual for the wander alert system when requested. The lack of comprehensive testing and supervision allowed the resident to leave the building undetected, constituting a failure to provide adequate supervision and maintain a safe environment free from accident hazards.