Failure to Prevent Resident Elopement Due to Inadequate Supervision and Non-Functioning Wanderguard
Penalty
Summary
A deficiency occurred when a resident with dementia and a known risk for elopement was able to leave the facility premises without staff knowledge. The resident, who had diagnoses including dementia, dysphagia, paroxysmal atrial fibrillation, and hypertension, was assessed as being at risk for elopement and had a care plan that included the use of a wanderguard bracelet and redirection as needed. Despite these interventions, the resident was found outside in the facility's parking lot by a visitor, who then brought the resident back inside and notified staff. At the time, the resident's wanderguard bracelet was not functioning and did not trigger an alarm when the resident exited the building. Staff interviews and documentation revealed that there was a malfunction with one of the facility's doors (Door #2), which required staff to perform every 15-minute checks on residents with wanderguard bracelets. However, the staff on duty were not informed about the need for these checks, and no documentation of the checks was present for the shift during which the elopement occurred. Additionally, the resident's wanderguard bracelet was found to be on the left ankle, contrary to the physician's order for it to be on the right wrist, and it was not working at the time of the incident. The facility's cameras were also not operational during the event, and there was confusion among staff regarding communication of the required increased supervision. Observations confirmed that the facility's doors were equipped with alarms and wanderguard keypads, but the system failed to prevent the resident's elopement due to the non-functioning bracelet and lack of staff awareness. The facility's policy stated that alarms are not a replacement for necessary supervision, but adequate supervision was not provided in this instance. The deficiency was identified through record reviews, staff interviews, and direct observation, affecting one resident out of four reviewed for elopement risk.