Failure to Prevent Elopement Due to Inadequate Supervision and Non-Functioning Wander Guard
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision and interventions to prevent elopement for a resident identified as being at risk. Facility policies required that an elopement risk observation be completed by a licensed nurse upon admission, re-admission, or significant change in status, and that interventions such as a Wander Guard device be implemented as needed. For one resident with dementia and a history of wandering, the care plan and physician orders specified the use of a Wander Guard, with function and placement to be checked every shift. However, documentation and interviews revealed that the resident was able to leave the facility unsupervised, and the Wander Guard system did not alarm as intended. On the day of the incident, the resident accessed the elevator, exited the building, and was later returned by EMS. Staff failed to recognize the event as an elopement, did not notify administrative staff until the following day, and did not perform a physical assessment or notify the resident's family upon return. The Wander Guard device was found to have a low battery, and system reports confirmed that the device's battery status had been low on the day of the elopement. Despite this, staff had charted that the Wander Guard was functioning for all shifts, and no immediate action was taken to check or replace the device after the resident was returned. Interviews with nursing staff and the administrator confirmed that the alarm system was not functioning properly prior to the elopement and that staff did not follow policy in responding to the incident. The administrator acknowledged that the Wander Guard should have been checked and replaced after the resident's return, and that no new interventions were implemented until the following day. The failure to ensure the proper functioning of the Wander Guard system and to respond appropriately to the elopement placed the resident in immediate jeopardy.
Removal Plan
- Resident 3's wander guard transmitter was replaced with a new transmitter and checked for function.
- A facility wide sweep was conducted on all in house wander guard transmitters to ensure proper function and battery life.
- Any transmitters with a low battery life or improper function were replaced.
- Disciplinary action was enforced with the staff member who failed to respond to the incident in a timely and appropriate manner.
- All licensed nursing staff were re-educated on the elopement policy and procedure.
- All licensed nursing staff were also re-educated on the wander guard system function and documentation.
- All new staff and agency staff will receive the education.
- The Director of Nursing or designee added checking the transmitter battery life to the weekly audit tool and the weekly audit tool would include wander guard placement and battery status.
- Any transmitters with a low battery status would be replaced at the time of discovery.
- The wander guard system check was completed daily and will continue to be checked for function daily.
- System check audits would be completed by the Building Services Director or designee daily for three months and transmitter audits would be completed weekly for four months, and then monthly for three months.
- Upon admission, all residents would receive an elopement assessment and the assessments would determine interventions as needed.
- Updates would be added to the resident care plan and discussed with the interdisciplinary team.
- Audit results would be reported to the Quality Assurance Performance Improvement committee to identify trends, further opportunities for quality improvement, and needs for additional education/re-education.