Failure to Prevent Elopement Despite Wander Guard and Supervision Protocols
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, cognitive impairment, and exit-seeking behaviors was able to leave the facility unattended despite being identified as an elopement risk and having a wander guard device in place. The resident, who was a new admission and had not adjusted to the facility, was independently ambulatory and had a care plan that included interventions for wandering and elopement risk. On the day of the incident, the resident exited the building and was found at a neighboring business approximately 20 minutes later. The wander guard device was in place at the time of the incident, and the resident was last seen in the facility about 20 minutes before being located outside. Staff interviews revealed gaps in supervision and monitoring, particularly during times when the receptionist was not present at the front desk. Some staff were not fully aware of the elopement protocols or the specific residents at risk, and there was confusion regarding the operation of the wander guard system, especially when doors were already open. The receptionist and other staff members could not recall seeing the resident leave, and there was uncertainty about who was responsible for monitoring the doors at the time of the incident. Additionally, some staff were unclear about the functionality of the wander guard system and their roles in preventing elopement. Observations and interviews indicated that while the facility had security measures such as magnetic locks, coded entry, and wander guard alarms, these systems did not prevent the resident from leaving the premises. The alarm system was tested and found to be functional, but it was not clear how the resident was able to exit without staff intervention. The lack of consistent supervision, unclear staff responsibilities, and insufficient training contributed to the failure to prevent the resident's elopement.