Failure to Prevent Elopement Due to Inadequate Supervision and Non-Functioning Wander Guard System
Penalty
Summary
The facility failed to ensure adequate supervision and the use of assistive devices to prevent accidents for two residents identified as being at risk for elopement. One resident, with a history of vascular dementia, severe cognitive impairment, and repeated falls, was known to have confusion and wandering behaviors. Despite being previously identified as at increased risk for elopement through multiple risk assessments, this resident was not provided with a wandering/elopement alarm and was able to exit the facility on two occasions. On the first occasion, staff were able to redirect her immediately, but on the second occasion, she exited through an exterior door, was found outside between two vehicles on the ground, and was subsequently assisted back inside. The care plan for this resident included interventions such as monitoring for wandering, providing diversions, and staying with the resident if exit-seeking, but these measures were not sufficient to prevent the elopement event. Another resident, also with severe cognitive impairment and a history of dementia, was identified as being at risk for elopement and was supposed to be monitored with a Wander Guard bracelet. However, observations revealed that the Wander Guard system was not functioning properly, as the front door did not automatically lock when the resident approached, failing on two out of three attempts. This deficiency was confirmed by facility leadership. The resident's care plan and physician's orders required monitoring of the Wander Guard device for placement and function every shift, but the system's failure was not detected until it was directly tested during the survey. The facility's elopement prevention policy required that all exits accessible to residents have devices in place to alert staff of possible elopement attempts, such as Wander Guard systems or other alarms. Despite these policies and documented interventions, the facility did not ensure that the required systems were in place and functioning for residents at risk of elopement. This resulted in residents being able to exit the facility unsupervised or without the intended safeguards in place, as evidenced by the incidents involving both residents.