Resident Elopement Due to Inadequate Supervision and Wanderguard Removal
Penalty
Summary
A cognitively impaired resident with a history of Wernicke's encephalopathy, chronic alcohol use disorder, seizure disorder, urinary tract infection, and hypertension was admitted to the facility and identified as being at risk for elopement. The resident was assessed as mildly cognitively impaired and was independent with activities of daily living, but required cueing and assistance at times. The care plan included the use of a Wanderguard safety bracelet to prevent unsupervised exit from the facility. Despite these interventions, the resident was able to remove the Wanderguard without staff knowledge. Staff discovered the device was missing and conducted a search of the resident's room and belongings, but could not determine how the device was removed. Subsequently, the resident was found to be missing during a routine check, prompting an elopement drill, notification of the DON, and involvement of local police. The resident's guardian later reported that the resident had arrived at her home, approximately two miles from the facility, after leaving the premises without staff awareness. Interviews with the resident and family confirmed that the resident had intentionally left the facility after removing the Wanderguard, walked through the community, and arrived at his guardian's home. The guardian was not concerned about the incident and did not notify the facility upon the resident's arrival. The facility's failure to maintain a safe environment and provide adequate supervision allowed the resident to elope undetected, despite being identified as at risk for such behavior.