Failure to Prevent Elopement Due to Inadequate Supervision and Wander Guard Monitoring
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who was assessed as an elopement risk and was equipped with a Wander Guard device. The resident, who had diagnoses including schizophrenia and anxiety disorder, demonstrated moderate cognitive impairment and a history of wandering and elopement. The care plan and physician's orders required the Wander Guard to be checked every shift, but documentation showed the last check occurred several days prior to the incident, and staff interviews confirmed that checks were only performed weekly, contrary to the orders and manufacturer’s instructions. On the day of the incident, the resident was discovered missing during a routine check for breakfast, prompting a facility-wide search and notification of law enforcement. The resident was later found offsite and returned by police. Review of facility records indicated that no alarms were triggered by the Wander Guard system at the monitored exits during the time the resident left. Observations and staff interviews revealed that the resident frequently accessed the designated smoking area, which was surrounded by a fence and padlocked gate but lacked a Wander Guard sensor. The resident was observed smoking alone in this area without staff supervision, despite being identified as an elopement risk. Further review of facility policy and manufacturer instructions indicated that the Wander Guard system should be tested daily, with results documented in the medical record. However, the facility’s practice was to test the devices weekly, and the policy did not specify the required frequency. The lack of adherence to the care plan, physician’s orders, and manufacturer’s guidance, combined with insufficient supervision in the smoking area, contributed to the resident’s ability to elope from the facility without detection.