F0689

D

Failure to Respond to Wander Guard Alarms and Supervise an At-Risk Resident

Milbank, South Dakota Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision for a resident identified as at risk for elopement, who left the building unsupervised. On the evening of 9/18/25, the resident exited through the facility’s back door. The wander guard system activated, sounding an alarm at the door, at the alarm panel, and sending an alert to staff radios. However, staff did not respond promptly: no staff were in the area of the alarm panel, not all staff heard the radio alert, and the resident was ultimately noticed and reported by another resident’s family member who heard the alarm and contacted an off-duty staff member. That off-duty staff member then called the facility, and the on-duty nurse went out and brought the resident back inside.

The resident involved had Alzheimer’s disease, a BIMS score of 9 indicating moderate cognitive impairment, a history of prior elopement, and a documented elopement risk assessment indicating she was at risk for elopement and should wear a wander guard and be checked frequently. Her care plan documented wandering, getting lost looking for her room, and wearing a wander guard on her walker, with staff instructed to monitor the wander guard and respond if she set off the alarm. The CNA sheets and a list in a binder identified her as wearing a wander guard. However, review of her treatment records from September and October 2025 showed no documentation that the wander guard was checked, and from November 2025 through mid‑February 2026, checks were only documented once daily at bedtime, despite an order for checks three times a day.

Multiple interviews and observations showed inconsistent understanding and implementation of alarm and elopement procedures among staff. Some CNAs reported that when the door panel alarmed, they only reviewed cameras and silenced the alarm if they saw nothing suspicious, and did not always go to check the door. One ward secretary silenced an active alarm after reviewing cameras without physically checking any door. A travel CNA, who had not received education upon returning to the facility, silenced the alarm panel without knowing its purpose or investigating the cause. Staff reported varying beliefs about whether wander guard alerts went to radios, and some staff did not carry radios, had radios turned down, or had them on the wrong channel, resulting in missed alerts. The DON described expectations that nursing staff carry radios with adequate volume and that wander guard alarms at exit doors send alerts to radios, but also acknowledged that maintenance only checked door panels monthly and that the facility did not have a device to test wander guard function beyond checking placement. Education on elopement and alarm response was inconsistently provided, with documentation showing that not all staff received the elopement education in‑service.