Complaint Investigation Report

LPA interviewed staff member who works near the front door. Staff stated R1 wears a wander guard, but staff did not hear an alarm go off and did not see R1 leave the facility. Staff stated she was alerted by relevant party that R1 was outside wandering. Record review indicated that R1 was placed on the wanderguard system due to R1 having an increase in confusion. Wanderguard consent form was sign by R1’s responsible party on 2/14/24 and wanderguard bracelet was placed on R1’s walker. Due to the information gathered LPA finds allegation to be SUBSTANTIATED.

LPA investigated allegation, "Staff did not ensure that facility front door alarm was working."LPA obtained resident records and conducted interviews with staff and relevant party. Relevant Party indicated on March 15 th at approximately 2 PM, they arrived at the facility to pick up R1 for a doctor’s appointment. Relevant Party reported they found R1 wandering in the facility parking lot unsupervised. Relevant party reported that facility was unaware resident was wandering outside the facility until she reported the incident. LPA interviewed staff member who works near the front door. Staff stated R1 wears a wander guard, but staff did not hear an alarm go off and did not see R1 leave the facility. Staff stated she was alerted by relevant party that R1 was outside wandering. LPA interviewed staff in which he stated he helped fix the wanderguard system. Staff stated that sensors were set on a low setting and due to R1 wearing their wanderguard bracelet on the walker, the sensors did not pick up the signal. Staff have updated the wanderguard system so sensors are on high and whenever a wanderguard gets within 6 feet, the alarm will signal. Administrator stated he is checking the wanderguard system weekly in precaution. Although the wanderguard system was in working order, the facility did not ensure the R1’s location of the wanderguard was placed properly to ensure wanderguard sensors would work properly. Due to the information gathered, LPA finds allegation to be SUBSTANTIATED.

Deficiencies cited on 9099-D. Appeal rights provided.