Failure to Prevent Wandering Resident from Accessing Stairwell Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident with vascular dementia and a high risk for wandering was able to leave their unit without staff knowledge, resulting in a fall with injury in a stairwell. The resident had a history of agitation, combative behavior, and was previously identified as a high elopement risk, with interventions including the use of a wander guard device. Upon readmission to the facility after a hospital stay, the order for the wander guard was not reinstated, despite the care plan indicating the need for such an intervention. The resident continued to display wandering behaviors after readmission, as documented in nursing progress notes. The care plan directed staff to ensure the resident wore a wander guard and to check its placement and function, but this was not implemented. The resident was last seen by nursing staff at the nursing station and was found approximately 20 minutes later by housekeeping staff on the landing of a stairwell, having accessed an egress door equipped with a delayed-egress mechanism and alarm. The alarm system was designed to alert staff when the door was opened, but the resident was able to enter the stairwell and fall without staff intervention. Interviews with facility leadership and staff did not clarify how the resident was able to access the stairwell unnoticed, despite known wandering behaviors and the presence of an alarm system. The resident sustained a right hip fracture and lacerations, requiring transfer to the hospital. The failure to reinstate the wander guard order and to provide adequate supervision and monitoring for a resident at high risk for wandering directly contributed to the incident.