Failure to Prevent Elopement of Cognitively Impaired Resident Despite Wander Guard System
Penalty
Summary
Facility staff allowed a severely cognitively impaired resident, who was at high risk for elopement and wearing a Wander Guard (WG) device, to exit a secured locked unit and subsequently leave the facility. The resident, diagnosed with Alzheimer's Disease, dementia, and unsteadiness on feet, had a care plan identifying elopement risk and an active order for WG placement. On the day of the incident, the resident was able to leave the 4th floor dementia unit and exit the building, despite the WG system being in place and documented as functioning. The incident occurred when the receptionist at the front desk heard the WG alarm sounding as multiple visitors exited the front door. The receptionist observed the resident, who was dressed in a straw hat and pink clothing, walking behind a group of people exiting the facility. The receptionist silenced the alarm by entering a code on the pin pad and allowed the group, including the resident, to leave without verifying the source of the alarm or preventing the resident's departure. The receptionist later acknowledged that she should have held the door and checked for residents before allowing anyone to exit. Interviews and camera footage confirmed that staff did not follow the facility's Secure Care/Wanderguard System and Elopements policies, which require staff to investigate alarms and attempt to prevent residents from leaving. The Director of Maintenance and other leadership confirmed that the WG system and doors were functioning properly, but staff failed to respond appropriately to the alarm. The resident was later found unharmed at a nearby grocery store by a relative and returned to the facility. The facility was unable to determine exactly how the resident exited the secure unit, and staff interviews revealed a lack of proper monitoring and response to the WG alarm.