Failure to Test Wander Guard Leads to Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident at risk for elopement, with an MD order for a wander guard device, had that device consistently checked for proper function. The resident had diagnoses including Alzheimer’s, dementia, diabetes, history of falling, and difficulty in walking, and was assessed as cognitively impaired with a BIMS score of 7, indicating severe cognitive impairment. The resident’s care plan and elopement risk assessment identified a history of wandering and risk for elopement, and the resident’s wander guard was ordered to be placed on the walker, with a requirement that nursing staff check its function daily on the 11:00 P.M. to 7:00 A.M. shift using a universal tester. On the date of the incident, documentation on the Treatment Administration Record for the 11:00 P.M. to 7:00 A.M. shift showed no evidence that the required wander guard function check had been completed. Nurse #1 later stated that she did not perform the wander guard function test during her shift because she did not want to wake the resident, although she observed that the device was attached to the walker. Facility policy and staff development information indicated that universal testers were available on each unit and that wander guard checks were to be conducted on the night shift, but this process was not followed for this resident on the day in question. As a result of the wander guard device not being tested and not functioning, the resident was able to leave the unit undetected. According to staff interviews and the facility’s report, the resident was last seen in the room watching television at approximately 6:30 A.M. and was discovered missing around 7:00 A.M. A search was initiated, and the resident was found on the first floor outside in the courtyard, sitting on the ground with the walker nearby. Staff confirmed that the wander guard device did not trigger an alarm when the resident left the unit, accessed the elevator, and exited to the courtyard, and it also did not alarm when the resident was brought back inside, demonstrating that the system was not functioning at the time of the elopement.
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