Improper WanderGuard Placement Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and ensure proper use of an electronic wander management system, resulting in an elopement. The facility’s policy required an environment free of accident hazards and the use of supervision and assistive devices to avoid preventable accidents. Manufacturer instructions for the WanderGuard Departure Alert System specified that if wrist placement was not successful, the bracelet should be mounted away from metal surfaces such as a wheelchair frame, as metal could interfere with the signal to the door modules, and that technical service should be contacted before placing the bracelet on a wheelchair. Resident 6 had dementia, disorientation, aphasia, severely impaired cognition, and required extensive assistance with ADLs. The resident had a recent reduction in psychotropic medication that led to increased exit-seeking behavior, and a WanderGuard device was placed on the resident’s wheelchair in response. On the date of the incident, Resident 6 exited the building through a service door without the WanderGuard system triggering an alarm. The resident was later found outside on the ground by bystanders, who assisted the resident back into the wheelchair and into the building, at which time the WanderGuard alarm sounded. Subsequent investigation, including door testing and review of security footage, showed that the resident left through the service door and that the alarm did not sound when the resident exited. The Maintenance Director determined that the WanderGuard, which had been placed on the back, bottom right side of the metal wheelchair frame, did not trigger the alarm when the wheelchair passed through the door, but did trigger when the device was removed from the wheelchair and passed through the door alone. The RN who placed the WanderGuard reported not testing it at the door and not having received training on correct placement, and the DON confirmed that no staff were trained on proper WanderGuard placement. The root cause analysis concluded that the placement of the WanderGuard on the metal wheelchair frame blocked the system from reading the device.
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