Elopement of Wander-Guard Resident Due to Unmonitored, Unalarmed Exits
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement for one resident identified as an elopement risk and wearing a Wander Guard device. The resident was admitted with schizophrenia, depression, cellulitis, and a local skin infection, and a subsequent H&P documented that the resident could make needs known but could not make medical decisions. The resident’s MDS showed moderately impaired cognition and independence with mobility, including walking and transfers, and indicated daily use of a wander/elopement alarm. An elopement evaluation documented that the resident wandered, and the care plan identified the resident as an elopement risk with interventions to check Wander Guard placement on the right wrist and document wandering behavior. Physician orders directed staff to check Wander Guard functioning and placement every night shift and to monitor for exit-seeking behaviors and related signs every shift. Despite these identified risks and interventions, a health status note documented that the charge nurse was unable to locate the resident at 6:21 p.m., and the resident had eloped from the facility while wearing a Wander Guard device. The Maintenance Supervisor reported that all doors leading directly into the facility had Wander Guard alarms that were checked and audible, but the two front doors leading to the street and the parking lot did not have Wander Guard alarms. The front entrance gate to the parking lot took 25 seconds to open and 25 seconds to close. An RN stated that no one was assigned to watch the front door monitor at the nursing station and that rounds were conducted in the morning, afternoon, and evening to ensure residents were not missing, but there was no official documentation of these rounds. As a result of these conditions, the resident was able to leave the facility with no arrangements for medical care or housing.
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