Failure to Prevent Elopement Due to Inadequate Supervision and Faulty Wander Guard Alarm
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate interventions and supervision to prevent an elopement by a resident who was assessed as being at risk for elopement. The resident, who had diagnoses including non-Alzheimer's dementia, seizure disorder, and schizophrenia, had a documented history of eloping from home. Physician orders were in place for the resident to wear a wander guard alarming device, with instructions for staff to check its placement and function regularly. The care plan also included interventions such as monitoring the device, redirecting the resident from exit doors, and providing redirection when visitors were present. On the day of the incident, the resident was found to be missing from the facility. Staff statements indicated that the door alarm was heard and subsequently disarmed, but the resident was not immediately located. The wander guard alarm was reportedly only functioning on one side of the door, and staff did not hear it activate. The resident was later found at a nearby gas station and was being transported across town by an acquaintance when the gas station manager recognized the resident and contacted the facility. The resident was returned without injury. Documentation and interviews revealed that while the door alarm was functioning, the wander guard alarm was not fully operational at the main entrance and employee entrance. Staff were engaged in other duties at the time of the incident and did not immediately respond to the alarm or notice the resident's absence. The facility's policy required identification of residents at risk for elopement and implementation of safety interventions, but these measures were not sufficient to prevent the resident's elopement in this instance.