Failure to Implement Elopement Interventions After Removal of Wander Guard
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for a resident identified as an elopement risk. The resident, who had diagnoses including diabetes mellitus, vascular dementia, and schizoaffective disorder bipolar type, was assessed as moderately cognitively impaired and required supervision or assistance with transfers and ambulation. The care plan identified the resident as an elopement risk due to a history of attempts to leave the facility and poor safety awareness, with interventions including the use of a wander guard bracelet. On 08/20/2025, the wander guard was discontinued after the resident repeatedly removed it, but no additional interventions or increased monitoring were implemented despite the resident remaining at risk for elopement. Following the removal of the wander guard, the resident continued to express a desire to leave the facility, as noted by staff who reported daily statements from the resident about wanting to leave or be discharged. However, there was no documentation of increased monitoring or alternative safety measures after the device was discontinued. The resident did not have a physician's order to go out on pass, and the care plan was not updated with new interventions to address the ongoing elopement risk. On 08/29/2025, the resident left the facility with a housekeeper, who was unaware of the policy prohibiting staff from taking residents out without proper authorization. The resident was transported approximately 45 minutes away to their responsible party's home without the required sign-out process or provider order. The responsible party was not expecting the resident and contacted facility staff to arrange for the resident's return. Interviews with staff and the housekeeper confirmed a lack of awareness and adherence to facility policies regarding elopement risk and resident outings.