Resident Elopement Due to Inadequate Supervision and Alarm Response
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple psychiatric diagnoses, who was wearing a Wanderguard bracelet, was able to leave the facility unsupervised. The resident was last seen by staff in the morning, and although the front door alarm sounded, the charge nurse assumed it was triggered by other residents accompanied by family members and did not conduct a facility-wide check to account for all residents with Wanderguard devices. The resident was not discovered missing until the local police contacted the facility after finding him approximately 1.3 miles away. The resident's care plan had previously identified a risk for wandering, and a Wanderguard had been placed after a prior incident where the resident was found outside the facility. Despite this, staff did not follow procedures to verify the whereabouts of all residents at risk when the door alarm was activated. Interviews with staff revealed that although they had received training on elopement procedures and the use of a binder listing residents with Wanderguards, the protocol was not followed at the time of the incident. The charge nurse did not initiate a sweep or census check to ensure all at-risk residents were present after the alarm sounded. The facility's failure to provide adequate supervision and to respond appropriately to the door alarm resulted in the resident leaving the premises undetected for approximately one hour. The resident was eventually located by law enforcement and returned to the facility without injury. The incident demonstrated a lapse in the implementation of established elopement prevention protocols, specifically in monitoring and accounting for residents identified as being at risk for wandering or elopement.