Elopement of Wandering Resident Due to Inadequate Supervision and Alarm Response
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention measures for a resident assessed as at risk for elopement. The resident had dementia, used a wheelchair for mobility, had impairment of one lower extremity, and a history of falls. A recent MDS documented that the resident wandered 1 to 3 days during the assessment period and that this wandering behavior had worsened compared to prior assessments. The resident wore a wander management bracelet that was documented as present and functioning on the day of the incident. The facility’s wander management system was designed so that when a resident with a bracelet approached an exit, the door locked and a visual indicator changed color, with an audible alarm sounding only if the door was pushed for approximately 15 seconds or if the door was ajar and unable to lock. On the date of the incident, the resident left the facility and went to a family member’s home located in front of the facility with the assistance of a visitor of another resident. The visitor, who was unaware of facility protocols, opened the exit door, assisted the resident out of the building, and walked the resident to the nearby home without notifying staff. Staff only became aware the resident was missing when the resident’s son called to report that the resident was in their driveway. A nursing note documented that when the resident was wheeled back into the facility, the door alarm sounded, indicating the wander bracelet was working. During the facility’s investigation, the Administrator reported that a staff member had heard the door alarm earlier, did not see any residents nearby, and turned the alarm off without further action. The DON confirmed that facility protocols did not require staff to immediately check or account for all residents wearing wander management bracelets when an alarm sounded and no resident was observed, and the written elopement policy only addressed procedures after a resident was established as missing, with no guidance on staff response to an activated wander management alarm when no missing resident had yet been identified.
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