Resident Elopement Due to Failure of Wander Guard System and Inadequate Supervision
Penalty
Summary
A resident with a history of Parkinsonism, major depressive disorder, and dementia with mood disturbance, who had demonstrated moderate to severe cognitive impairment, was able to elope from the facility without detection. The resident was last seen by staff in the evening and received medications and vital sign checks, but was later observed on security footage independently exiting the facility through a designated door in the early morning hours. The resident was not discovered missing until several hours later during a routine check, prompting a facility-wide search and eventual recovery of the resident outside the facility by a staff member. At the time of the elopement, the resident was wearing a wander guard bracelet, which failed to trigger an alert when the resident exited the building. The facility's investigation revealed that the functionality of the wander guard device had not been adequately tested for this resident, and the system did not activate as intended. Documentation showed that the maintenance department routinely checked the wander guard system at facility doors, but there was an oversight in ensuring the resident's individual device was operational, which contributed to the resident's ability to leave the facility undetected.