Elopement Risk Resident Exits Building Without Effective Wander Guard Alarm
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and proper use of an elopement alarm device for a resident at risk for elopement. The resident had diagnoses of cerebral infarction and unspecified dementia with behavioral disturbances, with an annual MDS identifying moderate cognitive impairment and daily use of a wander/elopement alarm. The resident’s care plans documented an elopement risk related to prior attempts to leave the facility unattended, impaired safety awareness, dementia, memory impairment, and exit-seeking behavior, including a history of packing belongings to go home and difficulty with redirection. Interventions included diversional activities, supervision as needed, consistent routines and caregivers, and use of a wander guard on the wheelchair. On the day of the incident, facility progress notes indicated the resident was agitated, wanted to go home, and had packed belongings. The resident managed to open a door and step outside into the snow. Camera footage later showed the resident self-propelling in a wheelchair toward the dining room door leading outside, pushing the door open, and exiting the building while two other residents and one staff member were present in the dining room. The staff member was observed escorting another resident out of the dining room and did not prevent the resident from exiting. The resident remained outside on campus until staff were observed with the resident and subsequently returned the resident to the building. The facility’s incident report documented that the resident exited through the south exit door by the dining room and that the wander guard alarm did not sound when the resident left. Observation later showed the resident’s wander guard pendant hanging under the wheelchair seat from a metal piece, secured by the wristband closure, rather than being worn on the wrist or ankle. The wander guard manufacturer’s manual specified that the strap was to be worn on the individual’s wrist or ankle, and a manufacturer representative stated that placing the pendant on metal could reduce effectiveness and cause malfunction. Interviews confirmed that the resident did not wear the pendant on the wrist or ankle, staff responsible for assessments had not reviewed the wander guard manual or verified safe alternative placement, and the DON was not aware that the pendant was required to be on the wrist or ankle, resulting in the device not being used according to manufacturer guidelines and failing to alert staff when the resident exited.
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