Failure to Prevent Elopement of High-Risk Resident Despite Wanderguard Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe environment for a resident at high risk for wandering and elopement, resulting in an actual elopement from the building. The resident had an Elopement and Wandering Risk Observation/assessment score of 12, which placed him at risk for wandering or elopement. His admission record documented diagnoses of dementia, bipolar disorder, cognitive communication deficit, atrial flutter, and a history of repeated falls. A BIMS score of 6 indicated severe cognitive impairment, and physician orders and care plans identified that he was not capable of making his own health decisions, was on anticoagulant therapy, and required safety measures and supervision, including a Wanderguard device and keeping him within supervised view as much as possible. The resident’s care plans included multiple risk areas: falls, elopement and wandering, and bleeding risk due to anticoagulant use. Interventions included identifying patterns of wandering, placing a Wanderguard on his right wrist, checking Wanderguard placement on the left ankle every shift, and providing supervision and reminders to ask for assistance. Orders also directed staff to monitor for signs and symptoms of bleeding every shift and to ensure the Wanderguard was functioning and replaced before expiration, with nursing staff instructed to notify the Activity Director for replacement. Despite these documented risks and interventions, a change of condition note recorded that the resident eloped in the early morning; he was last checked around 4:00 a.m. in bed and was found off premises by police near a baseball field and returned around 5:00 a.m. The note stated the Wanderguard was in place but did not alarm when the resident exited the facility. Interviews and observations further detailed the circumstances and gaps in supervision and monitoring. The resident reported leaving late at night to visit a friend who was a policeman and indicated he walked to a nearby baseball field, which required crossing a neighborhood intersection. The DON stated that nobody noticed the resident had left the facility and acknowledged the elopement care plan had not been updated to reflect the incident. The Activity Director stated she had been on leave and that she or anyone designated to cover her duties was responsible for tracking Wanderguard expiration dates, while the Human Resources Director did not recall being informed that the resident’s Wanderguard had expired. The Maintenance Director reported that door alarms were checked weekly, were loud when activated, and were monitored at two nurse stations, but he was unable to determine how the resident exited through the front door without triggering an alarm. The DON stated there was a potential for the resident to have fallen and sustained injuries when he eloped.
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