Failure to Ensure Proper Functioning and Monitoring of Wander Guard Device
Penalty
Summary
A resident with moderate cognitive impairment, as indicated by a BIMS score of 12, was identified as being at risk for elopement and was care planned to wear a wander guard device. The care plan intervention for the wander guard was initiated due to the resident's impaired cognition and previous elopement risk assessments. However, a subsequent elopement evaluation showed the resident was no longer considered at risk, and staff discontinued 15-minute safety checks. Despite the change in risk status, the resident was able to leave the building unattended and was found outside the facility, expressing a desire to go to the police department. Facility investigation revealed that the resident's wander guard device was not functioning properly at the time of the incident, which contributed to the resident's unsupervised exit from the building.