Failure to Prevent Elopement Due to Inadequate Supervision and Malfunctioning Wanderguard System
Penalty
Summary
A cognitively impaired resident with a history of elopement attempts, impaired safety awareness, hearing loss, and aphasia was admitted to the facility from an independent living apartment. Upon admission, the resident was identified as an elopement risk through multiple assessments, and interventions such as a wanderguard bracelet, every 2-hour checks, and a private sitter were implemented. Despite these measures, the resident continued to exhibit exit-seeking behaviors, including manipulating doors, cutting off the wanderguard bracelet, and attempting to leave the facility on several occasions. The care plan was updated to reflect these risks, and staff and family were aware of the resident's ongoing behaviors. On the day of the incident, the resident's private sitter left, and staff were not adequately informed of the change in supervision. The resident was last seen in his room, believed to be asleep, but was able to leave the room unsupervised. The conference room doors, which typically remained locked on weekends, were left open by the Dietary Manager, providing access to an exit door equipped with a wanderguard alarm system. However, the alarm system was malfunctioning and did not sound when the resident exited, allowing him to leave the building without staff knowledge. The resident walked down the main road, passed a security gate, and was found by a bystander near a busy intersection with injuries, including a facial contusion and skin tears. Interviews and record reviews confirmed that staff were unaware of the resident's absence until notified by security and emergency services. The malfunctioning wanderguard system was later confirmed through testing, and the lack of communication regarding the sitter's departure contributed to the lapse in supervision. The resident's room was located near the exit, and the path to the door was unobstructed. The incident resulted in the resident being found off campus with injuries and highlighted failures in supervision, monitoring, and the effectiveness of safety systems for residents at risk of elopement.