A resident was readmitted from the hospital, and staff did not check his prior care plan and assessments for risk of elopement and behavior issues. The 91-year-old dementia resident who had lived in the facility for 10 months was found wandering in the main lobby. The staff member took the resident back to his unit. The staff on the resident’s floor were surprised and were not aware that he had wandered off their unit. The resident had previously worn a WanderGuard, but he did not have one reapplied when he returned from the hospital.
Elopement and unsafe wandering continue to be high-risk resident safety issues. When developing systems to prevent elopement and unsafe wandering, there are many components. One area that can be overlooked is how to address residents who are sent to the hospital and return. Residents with a history of unsafe wandering or who are identified at risk for elopement wear an “alert bracelet” (Example brand names: WanderGuard, Secure Care) that prevents the resident from leaving the place where he or she lives without appropriate supervision. At times of transfer to a hospital, these alert bracelets are removed. A standard practice to ensure a resident receives the appropriate interventions to address the risk of elopement and unsafe wandering is assessment of all residents immediately upon return from a hospital. This practice requires implementation of a clear process with specific personnel identified to complete the assessment. Once the role and responsibility of who performs the assessment is identified, training should occur on how and when to complete the assessment. We all know residents can return at any time to the facility from the hospital. This risk assessment should happen immediately upon the resident’s return. A monitoring/auditing process should be implemented to ensure the risk assessment was completed on time and is accurate, the appropriate follow up of placing an alert bracelet was completed, staff were notified, and care plan updates were completed. Report the results to the QAPI committee to determine if any further actions are needed.
Implementing a consistent practice of assessing all residents’ risk related to elopement and unsafe wandering upon return from a hospital reduces the risk of overlooking application of a bracelet for a returning resident who previously wore one for safety.
