Failure to Prevent Elopement and Ensure Resident Supervision
Penalty
Summary
A resident with a history of traumatic brain injury, severe cognitive impairment, and identified as an elopement risk was able to leave the facility unsupervised during the night. The resident was wearing a WanderGuard bracelet, a device intended to prevent unsupervised exits, but the facility's alarm system failed to alert staff when the resident exited. Multiple staff members, including nurses and CNAs assigned to the resident's care, did not visually check on the resident during their shift, despite facility expectations and policies requiring residents to be checked at least every two hours. The last known observation of the resident was at approximately 9:40 p.m., after which no staff reported seeing or checking on her until the following morning. The resident was discovered missing during the day shift when a nurse went to check her blood sugar and found her room empty. A search was initiated, and the resident was found approximately 0.6 miles away from the facility, exhibiting signs of hypothermia and abnormal vital signs. Upon return, the resident was confused, had a low body temperature, and complained of pain. The WanderGuard device was found to be intact and functional when tested after the incident, but facility investigation revealed issues with the door's latch and mag-lock, which may have prevented the alarm from activating as intended. Staff interviews indicated a lack of awareness regarding which residents were at risk for elopement, and elopement risk was not included on assignment sheets. Documentation and staff statements confirmed that the resident had a care plan identifying her as an elopement risk, with interventions such as regular checks and use of the WanderGuard. However, these interventions were not consistently implemented, and staff did not follow the facility's policy for supervision and monitoring. The failure to provide adequate supervision and to ensure the effectiveness of the WanderGuard system resulted in the resident's unsupervised exit and exposure to harm.