Failure to Ensure Functioning Wander Alert System
Penalty
Summary
The facility failed to develop and implement a process to ensure the wander alert system was functioning properly, affecting two residents who utilized wander alert devices. One resident, who had diagnoses including vascular dementia, Alzheimer's disease, and bilateral below-the-knee amputations, was identified as high risk for elopement and wore wander alert bracelets on both the left wrist and wheelchair. Despite these precautions, the resident was able to exit the facility on two separate occasions. In one incident, the wander guard did not work, allowing the resident to leave through the front entrance doors, which had not locked after being recently opened. In another incident, the resident was found outside in a culvert with the wheelchair on top of him after pushing and holding the exit door long enough for the emergency release to activate, despite wearing the wander alert device. Interviews with staff revealed ongoing issues with the door locking mechanism. Nursing assistants and an LPN reported that the doors would alarm when the resident was near but did not physically lock, and this issue had been occurring for several weeks. Staff stated that the malfunction had been reported to management, but the problem persisted. The administrator confirmed that the facility had been without a maintenance director for about two weeks and had relied on maintenance staff from another facility to inspect the doors. However, the inspections did not identify or resolve the underlying issue with the wander alert system and door locks. Further review of the facility's testing procedures and manufacturer recommendations indicated that the required weekly testing of the wander alert system was not being conducted as specified. The former maintenance director admitted to not testing whether the doors would unlock if a wander alert device was near and was unsure who to contact for technical issues. The regional director of operations and other staff used a handheld remote to test the doors, but this did not replicate the actual conditions under which the system failed. Documentation and interviews confirmed that the process for ensuring the wander alert system's functionality was inadequate, leading to repeated failures to prevent elopement.