CLASS AA CITATION -- PHYSICAL ENVIRONMENT
A 76 year old male resident with senile dementia wandered out of the facility and was struck and killed by a car on the freeway on 2/17/11. It was the second time in five days that the resident had wandered from the facility, and he had been a resident of the facility for less than a week. Even though a WanderGuard bracelet had been placed on the resident’s wrist after the first incident, this did not prevent the second incident from occurring because the WanderGuard alarm system had not been fully installed on all exit doors at the facility. The facility was cited for failure to provide adequate supervision and assistive devices as well as for failure to maintain a safe and secure environment for the resident, which was determined to be a direct cause of the resident’s death.