Failure to Replace Wanderguard Results in Resident Elopement
Penalty
Summary
Facility staff failed to ensure that a resident identified as at risk for elopement consistently had a wanderguard device in place as ordered by the physician. The resident, who had a primary diagnosis of Alzheimer's Disease and a history of wandering and attempted elopements, was assessed as requiring a wanderguard on the left ankle. Despite this, staff documented on multiple occasions over several months that the resident did not have a wanderguard in place, with no documentation of replacement or explanation for its absence. The resident's care plan and physician orders required the wanderguard to be checked every shift and as needed. Progress notes repeatedly indicated the absence of the device, but there was no evidence that staff replaced the wanderguard or communicated the issue to the DON or administrator. Interviews revealed that some staff believed the resident was no longer a safety risk for elopement, while others did not follow up on the missing device, and the DON and administrator were not made aware of the ongoing issue until after the resident left the facility. The deficiency culminated when the resident left the facility without staff knowledge and was found by a community member sitting on a curb near the facility. The resident was returned to the facility with an abrasion and was not wearing a wanderguard at the time. Staff interviews confirmed a lack of consistent action to replace the missing device, despite repeated documentation of its absence and the resident's known risk factors.