Failure to Ensure Elopement Prevention Measures for Residents with Dementia
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents with dementia and a history of wandering or elopement. One resident, who had a documented history of elopement and was assessed as being at risk, did not have the required Wander Guard device placement and functioning checks documented every shift as ordered by the physician. Review of the Treatment Administration Records (TARs) revealed multiple dates where these checks were not performed or documented, despite facility policy and care plan interventions requiring such monitoring. Interviews with staff and the Director of Nursing (DON) confirmed that the expected protocol was not followed, and the risk for this resident was identified as elopement. Another resident, admitted with dementia, muscle weakness, unsteadiness, and a recent history of elopement, was not provided with a Wander Guard device upon admission, contrary to facility policy. This resident had been recently hospitalized after being found wandering and was discharged to the facility for close monitoring. Despite ongoing issues with wandering and a physician's assessment indicating the need for close monitoring and safety measures, the resident did not have a Wander Guard device in place prior to an elopement incident. The resident was found outside the facility by staff after the incident, and it was confirmed through interviews and record review that the device was only applied after the elopement occurred. Facility policies reviewed indicated that residents at risk for elopement should have a Wander Guard device applied and checked daily, and that interventions to reduce accident risks must be implemented and documented. The DON acknowledged that these policies were not followed for both residents, resulting in lapses in supervision and monitoring that led to one resident eloping and another being at increased risk for elopement due to inconsistent monitoring.