Failure to Prevent Elopement Due to Equipment Malfunction and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a diagnosis of dementia exited the facility without staff knowledge. The resident was identified as high risk for wandering and had a history of exit-seeking behaviors. The resident was wearing a WanderGuard bracelet, which was checked and found to be working earlier in the morning, but later malfunctioned, allowing the resident to leave the building. Staff observed the resident outside and assisted them back into the facility, but there was no documentation of how long the resident was outside or a nursing assessment following the incident. The facility's policies required staff to be knowledgeable about elopement procedures and to document elopement risk, WanderGuard bracelet status, and any incidents or malfunctions. However, the care plan for the resident only included checking the WanderGuard function every shift, with no other interventions for exit-seeking or elopement risk. Staff interviews revealed a lack of awareness and training regarding new safety devices, such as a motion detector installed after the incident, and no one was assigned responsibility for monitoring it. Additionally, exit doors and alarms were not routinely checked for functionality unless a problem was reported, and the motion detector was found to be nonfunctional during the survey. Communication and reporting failures were also identified. The incident was not reported as an elopement, and there was no follow-up assessment or notification to the resident's family. Staff members, including the DON and AA, were unclear about the details of the incident, and there was no documentation of extra checks or interventions for the resident after the event. The lack of investigation and reporting, combined with equipment failures and insufficient staff training, contributed to the deficiency.