Failure to Assess and Intervene for Elopement Risk and Inadequate Wanderguard Battery Testing
Penalty
Summary
The facility failed to adequately assess and implement interventions for residents at risk for elopement, specifically for one resident who was cognitively impaired with a history of dementia, anxiety disorder, and wandering behaviors. This resident had a documented history of elopement and exit-seeking behaviors, including pounding on doors and standing at exit doors, but the care plan did not include interventions for these behaviors or document the reasons for the resident's attempts to leave the facility. The care plan also lacked specific guidance on how often to check the battery of the resident's wanderguard tag, a device intended to alert staff if the resident attempted to leave the premises. Additionally, the facility failed to follow manufacturer recommendations for testing the batteries of wanderguard tags for three residents identified as at risk for elopement. While staff checked the physical placement of the wanderguard devices every shift, there was no evidence that the batteries were tested weekly as required by the manufacturer. Instead, maintenance staff tested the batteries monthly, and there was no documentation of these checks. Interviews with staff and the DON revealed a lack of awareness regarding the recommended frequency for battery testing and an absence of documentation or policy guidance on this matter. The facility's elopement prevention policy did not provide adequate direction on monitoring and managing residents at risk for elopement or specify how often wanderguard batteries should be tested. Multiple staff interviews confirmed that interventions for exit-seeking behaviors were not included in the care plans, and the focus was primarily on door security rather than addressing the underlying causes of residents' attempts to leave. The deficiency was further evidenced by an incident in which a resident successfully eloped from the facility and was found outside, as well as another incident where the same resident attempted to leave again shortly after.