Failure to Respond to Wander Guard Alarm Leads to Resident Elopement
Penalty
Summary
A deficiency occurred when a resident identified as high risk for elopement, with diagnoses including a displaced hip fracture, chronic kidney disease, schizophrenia, and anxiety, was not adequately supervised despite being on wander guard precautions. The resident had a documented history of exit-seeking behaviors and was assessed as cognitively impaired and unable to make independent decisions. The care plan included interventions such as the use of a wander guard, routine checks of the device, and monitoring for elopement risk, but did not specify staff response protocols for wander guard alarms. On the day of the incident, the resident left the facility by calling a cab and was able to exit through the front door. Although the wander guard alarm was triggered, staff did not respond to the alarm, and there was no one present at the front desk to intervene. The absence of immediate action allowed the resident to leave the premises undetected for approximately two and a half hours. Staff only became aware of the resident's absence when attempting to deliver medications and meals, at which point a search was initiated. The resident was eventually found stranded at a local store by members of the public and returned to the facility. Review of facility policies revealed that while the use of wander guards and care plan updates were required, there was a lack of clear guidance on staff roles and required actions when a wander guard alarm was activated. This contributed to the delayed response and failure to prevent the resident's elopement.