**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and document review, the facility failed to conduct comprehensive elopement risk assessments for 2 of 3 residents (R1, R3) identified as an elopement risk. Additionally, the facility did not promptly respond to a sounding Wanderguard alarm or ensure proper functioning of alarmed exit doors. This resulted in an immediate jeopardy when R1 left the facility and was found half a mile from the facility.The IJ began on [DATE], when it was identified R1 had eloped through the facilities south door, with the alarm sounding and walked 0.5 miles away from the facility. On [DATE] at 1:26 p.m., the director of nursing (DON) and business office manager were notified of the IJ. The IJ was removed on [DATE] at 12:55 p.m., after it could be verified the facility had implemented an acceptable removal plan. However, non-compliance remained at a D for isolated scope and severity which indicated no actual harm, with potential for more than minimal harm.Findings include: R1's face sheet dated [DATE], identified R1 admitted to the facility 4/2025, with diagnoses of dementia (decline in cognitive function), morbid obesity (overweight), aphasia (language disorder that affects communication and comprehension), and signs and symptoms involving cognitive functions and awareness (encompass a range of mental processes including memory, attention, language, and problem-solving abilities).R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 did not talk and was rarely/never understood but sometimes understood others. R1 had severely impaired daily decision-making skills. Wandering occurred 1-3 days but did not trigger a significant risk of getting to a potentially dangerous place or outside of the facility but intruded on privacy/activities of others. R1 was able to walk without assistive devices, dependent on staff for lower body dressing and substantial assistance with upper body dressing. R1's Brief Interview for Mental Status (BIMS) dated [DATE], identified R1 was unable to complete the interview, which indicated staff completed the interview and identified a memory problem with short- and long-term memory, and moderate impairment with decisions.R1 did not have a comprehensive elopement risk assessment completed.R1's care plan dated [DATE], identified behaviors related to dementia and at risk for wandering. Interventions included: address wandering behavior by walking with or attempt to redirect from inappropriate area, engage in divisional activity ([DATE]); intervene wandering as needed to protect rights and safety of others, approach in a calm manner, divert attention, remove from situation/take to another location ([DATE]); Wanderguard placed on ankle, staff to ensure placement each shift ([DATE]).R1's physician orders dated [DATE], identified a Wanderguard was placed on left ankle and make sure Wanderguard was in place and functioning daily. Additional orders dated [DATE], identified to document frequency of R1 wandering into other resident's rooms and if R1 was redirectable.R1's progress notes from [DATE]-[DATE], identified R1 wandered into other resident rooms and walked a significant amount around the building. R1 was not always redirectable for staff.R1's progress note dated [DATE] at 2:49 p.m., identified at approximately 10:46 a.m., R1 eloped from the facility via the south door. The alarm was sounding. NA-A notified by a resident that R1 had walked past her door but did not come back around and pass her door again. NA-A alerted staff of elopement. Staff searched outside, asked community members that were in the area, and were directed on where R1 was seen. R1 was assessed for injuries and offered water upon return to facility, Wanderguard assessed and working properly. South door examined and noted that it would not sound if the door was not fully closed. R1 placed on 15-minute checks. Physician, family member, and DON notified of incident.R1 was found as 0.5 miles from the facility. The Weather Channel identified the temperature on [DATE] to be ranged from 60-79 degrees Fahrenheit with stray thunderstorms.R1's Resident Safety assessment dated [DATE], identified 15-minute checks began on [DATE] at 11:45 a.m., and ended on [DATE] at 10:00 p.m. when the door was fixed. During an observation on [DATE], R1's room was located on the north hall, near the nurses station. At 9:37 a.m., activity staff was observed walking down the hall and met R1, who was walking the north hall independently and began to dance next to him down the hall. At 9:41 a.m., R1 walked to the end of the hall and entered the chapel, with an exit door and keypad next to the door, R1 sat in a recliner. No staff were present in chapel. Another resident was looking out the window, next to the exit door. R1 appeared short of breath and had a white band sticking out of the top of his right sock, consistent with a Wanderguard bracelet. At 9:45 a.m., R1 stood up and went to the exit door and looked out the glass door, turned around and began walking back down the hall. At 9:55 a.m., R1 continued to walk down hallways. During a phone interview on [DATE] at 3:26 p.m., housekeeper (HSK)-A stated she witnessed R1 walking around the facility earlier in the morning on [DATE]. HSK-A heard the noise of the alarm, and saw all the nurses were looking around and checking rooms. HSK-A was alerted a resident was missing. HSK-A left the facility and went toward the park. HSK-A saw people at the park and asked if they had seen a person matching R1's description. HSK-A was directed in the direction R1 was seen. HSK-A caught up to R1 between the library and the post office. HSK-A called the facility informed licensed practical nurse (LPN)- where they were and that she was going to stay with R1. NA-C brought a wheelchair. A nurse and two other nursing assistants also arrived to HSK-A's location.During an interview on [DATE] at 10:13 a.m., NA-B stated the Wanderguard helps to tell staff when a resident goes outside because the door alarm will go off. The door would alarm and lock if a resident with a Wanderguard got too close, and a code was needed to open the door and turn off the alarm. The south hall was a high traffic area with an exit door. NA-B stated there was no way the door would open with a Wanderguard. It was possible a person exited from that door and R1 managed to leave. R1's wife would take him outside, but facility staff does not because they did not know if R1 would come back inside willingly. R1 went room to room in the halls and staff just keep an eye on him. On [DATE], NA-B did not hear the alarm sounding and stated a person needed to be down the south hall or in the lobby to hear the alarm. NA-B was informed the south alarm was sounding, R1 was missing, and no one saw R1 exit the building. The search began room to room looking for R1. One staff member got in a car and drove to R1's location as reported by someone in the community. NA-B was unsure how long R1 was missing but he was several blocks away and was difficult to get him to come back to the facility. After R1 was back in the facility he was on 15-30 minute checks. NA-B did not receive re-education from the facility after the incident.During phone call on [DATE] at 8:27 a.m., NA-A stated R1 would lay on his bed and sometimes walk around the building. On [DATE], NA-A went to answer a call light on the south hall, and heard the south door alarm sounding. The south hall door was closed. NA-A looked down the south hall first and then saw RN-C and asked RN-C to walkie talkie for staff to look for R1 down the other halls. NA-A looked down her assigned halls and another NA and RN-C looked down the other hall. Sometimes, R1 would wander through the employee doors so NA-A went down to the laundry room and R1 was not in there. NA-A went outside and looked around the parking lot and did not see R1. Someone outside the facility told HSK-A R1 was down by the post office and HSK-A found R1. NA-A ran down the road and could see HSK-A with R1 slowly walking back to the facility. R1 was on 10-20 minute checks for at least the day or next couple of days. When registered nurse (RN)-B was interviewing staff after the incident, she had the south door slightly open and in the 45 minutes it was open the alarm did not go off and that was how we thought it was the door. Although the facility knew the door alarmed, they had not checked outside of the building but checked inside the facility first. During a phone call on [DATE] at 9:54 a.m., NA-C stated staff go in and out of the south door a lot. NA-C was working in the laundry department and was in the backroom on [DATE]. R1 was an elopement risk because he constantly walks the facility. NA-A came into the laundry room looking for R1. NA-C did not hear the alarm. NA-C immediately went to the main lobby and heard the south alarm going off. NA-C immediately went outside and started looking around the premises. NA-C heard HSK-A had found R1 and went to meet up with them. R1 looked really tired and exhausted so NA-C ran back to the facility and got a wheelchair and wheeled it back to R1 and HSK-A. R1 walked most of the way back, it was probably the last four blocks that R1 decided to sit in the wheelchair and ride back. NA-C was aware R1 had 15-minute checks the rest of the day and the maintenance director (MND)-A was called to check the south door because of the latch and staff were to make sure the door was latched when coming and going. NA-C was unaware of any education provided after the incident. During a phone interview on [DATE] at 10:07 a.m., NA-D stated [DATE] was her first shift at the facility and she had not had training on alarms or elopement. NA-D arrived at 5:30 a.m., and R1 was awake and walking the halls. NA-D noticed R1 was walking around the facility and checking the doors and staff told her that R1 had been up doing that all night. NA-D was in a room with a resident on the south hall and stated she kept hearing what sounded like an alarm, beep, beep, beep. NA-D was unsure what it was. NA-D was told by another NA, a resident got out of the building. Staff went room to room and when they could not find R1, went outside. A community member took a staff person down to R1. NA-D was unsure if the facility had an elopement plan for R1 but knew he should not exit the facility alone because he had the Wanderguard on. During a phone interview on [DATE] at 8:53 a.m., LPN-A stated the south door alarm is not as loud as the main entrance alarm but it can be heard at the nurses station and down the halls. There was no specific elopement procedure, usually staff are assigned to halls to search bathrooms, closets, everywhere and alert staff if the resident was found. At the time of the incident on [DATE], RN-C and an NA had been in a room with the door closed on the north hall. LPN-A was on the east hall providing a treatment to another resident when RN-C called to her on the walkie-talkie system to come to the front desk right away. LPN-A was unsure of the specific time RN-C called her but thought it was around 10:00 a.m. LPN-A went to the front desk and RN-C stated they were looking for R1. The south door alarm was sounding. LPN-A stated she and RN-C started to think maybe R1 went outside with someone as he had a tendency to go in the activity room, which was located on both sides of the south door and other resident rooms. Dietary, housekeeping, laundry, and nursing departments all looked for R1. LPN-A stayed inside the building by the nurses station and her assigned hall as RN-C went outside the facility. A staff person walkie-talkie they saw R1 and that is how LPN-A knew he was found. R1 was brought back to the facility in a wheelchair, he was exhausted. LPN-A completed a full set of vital signs, gave water, checked R1's feet for blisters, and began 15-minute checks upon return. RN-C notified RN-B of the incident. LPN-A did not notify the police of the incident. During an interview on [DATE] at 9:50 a.m., RN-A stated R1 wandered around the facility and into other resident rooms. RN-A recalled R1 was placed on 15-minute checks after he eloped on [DATE], as the facility determined the south door he exited from did not latch properly. RN-A thought the 15-minute checks continued until the south door was fixed. RN-A was not aware of precautions put in place for the other resident (R2) that resided in the facility on [DATE] and had a Wanderguard. RN-A was unaware of any education or facility drills completed on elopement after the incident.During a phone interview on [DATE] at 10:43 a.m., RN-C stated she was not sure if the facility had an elopement assessment. RN-C had noticed R1 going to doors and pushing on them a couple of times on the morning of [DATE]. When R1 eloped on [DATE], RN-C was assisting with a transfer in another resident's room. When they finished the transfer and left the room, they heard the door alarm sounding. RN-C immediately thought of R1, and her and the aide went to R1's room and he was not in there. RN-C and the aide looked around for R1 and RN-C used the walkie-talkie and notified LPN-A that the door alarm was sounding, and they could not locate R1. Staff were notified via walkie-talkie that R1 was missing. There was not a specific procedure that was followed, everyone just scrambled. LPN-A was more familiar with the facility and directed staff where to look. R1 was found by the post office. A NA met up with the staff that found R1 and once RN-C knew R1 was found and where the location was, RN-C met up with R1 and the staff and walked with them towards the facility. Another staff member brought a wheelchair because R1 appeared very tired and R1 sat in it and was transported back to the facility. R1 had a full body exam for injuries and 15-minute checks were initiated. LPN-A notified the nurse practitioner. RN-C was unaware if the police were notified but knew she had not notified them. A sign was placed on the south door to make sure it shut completely if you go in or out of it until it was fixed. The facility thought the south door was ineffective and that was how R1 was able to get out.During a phone interview on [DATE] at 10:24 a.m., RN-B stated the facility does not have a formal assessment for elopement risk. If a resident attempted to leave the facility, that was when a Wanderguard was put on. The door system will lock and an alarm will sound when a resident attempts to open the doors. R1 wandered the facility daily and frequently pushed on exit doors. On [DATE], LPN-A called RN-B, who was the designated on-call nurse at the time and notified her R1 had eloped and was already back at the facility. RN-B recalled R1 had walked out the south door, staff heard the alarm and started looking for R1. Staff did not see R1 anywhere nearby or on facility grounds. Some staff saw community members in the nearby park and approached them and asked if they had seen R1, and they had and pointed the direction R1 went. HSK-A was able to see R1 in the distance and communicated to LPN-A that R1 was found but was a distance ahead of her. HSK-A caught up to R1 and was able to convince him to turn around and began walking back with him. Another staff came with a wheelchair and R1 sat in it and was wheeled back to the facility. LPN-A checked R1's vital signs and gave water to hydrate. No injury was noted to R1's body during physical exam. RN-B investigated the south door Wanderguard function. There were times where the door would not fully latch so RN-B notified MND-A of her findings. RN-B had staff initiate 15-minute checks for R1 while the door was not functioning. RN-B was not concerned about initiating 15-minute checks for R2 as R2 had a motion sensor alarm placed while he was in his room and staff always escorted him to and from the dining room, where he remained supervised. RN-B was not aware if anyone checked the functionality of the door alarms on a regular basis. During an interview on [DATE] at 10:59 a.m., maintenance director (MND)-A stated he was unaware when the Wanderguard door system was installed but it was prior to him working at the facility and he had been the maintenance director for at least a year. MND-A thought there were five doors with the Wanderguard system on them. The facility had never had a maintenance plan in place for the doors to be checked as far as MND-A was aware and the doors had never been checked and he did not keep a log. MND-A was made aware of the door not properly latching on [DATE]. MND-A adjusted the door and hinges and ordered a new hydraulic closer. MND-A was unsure when the door was fixed but thought it was probably within that week. The facility amazon order dated [DATE], identified an order for a Dynasty Door Closer, commercial grade size 4 spring, hydraulic automatic series 4000 Door Closer Sprayed Aluminum was ordered on [DATE], shipped to the facility on [DATE]. The facility did not identify when the order arrived at the facility.During an interview on [DATE] at 9:33 a.m., DON stated the facility has never done elopement risk assessments. During a subsequent interview at 11:11 a.m., DON stated the facility determined if a resident is at risk for elopement upon admission when they talk with the family, or if they are a known wanderer from information obtained from the hospital or facility resident transferred from. After R1 returned to the facility staff gave him fluids, performed a skin check, completed vital signs, and placed him on 15-minute checks to ensure it would not happen again. To mitigate elopement, interventions in the care plan include distraction, activity, staff interaction, redirection, typical dementia type interventions included to deter them going in that direction. The Wanderguard company was not notified to assess the system as the facility felt it was the hydraulics leaking and the door was not locking, it was slightly ajar, so R1 was able to get out. If the door had been working properly it would have locked and stayed locked so R1 would not have been able to leave the facility. The facility does not test the doors to make sure the Wanderguard system is working properly. The facility had an elopement policy, staff communicated on walkie-talkies, and each nurse should take their assigned NA's, have them do an all-clear check when an alarm went off. R1 was removed from 15-minute checks on [DATE] as maintenance had done repair on the door hinge that allowed the door to shut securely while waiting for the hydraulic part. Since the door was able to close, staff felt R1 was safe, and he was removed from 15-minute checks.The IJ was removed on [DATE], when the facility revised and implemented the following that was verified through staff interview on [DATE].A formal Elopement Policy and Procedure, including: Definitions and identification of elopement and wandering behavior Required interventions for at-risk residents Staff roles and responsibilities in prevention and response Detailed response procedure Monthly audits and staff retraining requirementsDevelopment and implementation of Elopement Risk Assessment Tool which included: Tool considers history of wandering, cognitive status, behavioral indicators, and functional mobility All residents were assessed using this tool by nursing leadership Results of assessments were reviewed with Interdisciplinary Team (IDT) and incorporated into resident care plans Elopement risk assessment to be completed upon admission, quarterly, and PRN upon any changes noted. Information obtained to be used in creating an individualized care planCare plan revisions: For all residents identified at risk for elopement, individualized care plans were updated to include: clear, tailored interventions (room location, increased checks, redirection strategies); use and maintenance of Wanderguard devices, diversional activities and environmental controls, updated completed and singed by IDTWanderguard and Door alarm monitoring procedure: Weekly door and wander guard system inspection protocol has been established and incorporated into the facility maintenance schedule Maintenance will test each wander guard enabled door weekly and document results in a newly implemented door alarm inspection log Nursing staff are required to verify wander guard functionality at the beginning of each shift and document it All staff to be educated on immediate alarm response time to decrease the potential risk to the resident for harm. Staff education and re-training: All staff educated on: revised elopement policy and procedure, use of the elopement risk assessment tool, wander guard system checks and documentation, emergency response protocols for elopement; training included scenarios and drill; attendance logs and training on file, new hires will receive this training during orientationMonitoring and Quality Assurance: The Quality Assurance and Performance Improvement (QAPI) committee will: review all elopement related incidents monthly, audit 10 elopement risk assessments and care plans weekly for 8 weeks, then monthly for four months, audit door alarm logs and shift wander guard checks weekly, results will be reviewed during monthly QAPI meetings, corrective actions will be implemented for any identified deficiencies R3's face sheet dated [DATE], identified R3 admitted 5/2025. Diagnoses included anxiety disorder, and dementia.R3's optional state assessment MDS dated [DATE], identified moderate cognitive impairment. No wandering or behaviors.R3 did not have a comprehensive elopement risk assessment completed.R3's care plan dated [DATE], identified self-care deficit with interventions requiring assistance of one staff with dressing. A care plan focus dated [DATE], identified R3 had diagnoses of dementia, poor memory recall, and anxiety. R3 was new to the facility and needed explanations, reminders, and assistance to attend activities of her choosing. Interventions included offer to sit outside with R3 when the weather is nice. A second focus on [DATE], identified R3 had impaired cognitive function related to dementia. Intervention on [DATE], identified R3 had a history of wandering away from the facility, order to have Wanderguard on and checked each shift to ensure placement.R3's progress note dated [DATE] at 1:00 p.m., identified a nurse-to-nurse report from the hospital. The hospital stated R3 had dementia with sundowning behaviors and does not always know place and time. At 9:12 p.m., R3 became more upset as the night progressed and had no idea why her family dumped her at facility.R3's progress note dated [DATE] at 1:26 p.m., identified R3 exhibited poor memory recall by forgetting her recent hospital stay as well as reason for residing at facility.R3's progress note dated [DATE] at 2:57 p.m., identified R3 was seen pacing back and forth in the hallway, unable to find her room. Walked with R3 towards her room and she was able to remember where it was.R3's progress note dated [DATE] at 9:34 p.m., identified R3 experienced confusion, believed she was at work and that she able to walk herself home.R3's physician dictation note dated [DATE], identified R3 had increased confusion, which contributed to her long-term residency at facility. R3 does have sundowning, easily redirected.R3's progress note dated [DATE] at 8:18 p.m., identified R3 was found outside on the east side of the building. R3 was confused on what door to enter. R3 is able to go outside unsupervised and is alert and orientated times three and understood that she got turned around. DON and on-call doctor notified and a verbal order was obtained to put a Wanderguard on R3. At 8:24 p.m., a dietary note identified R3 was seen walking on the grass by the dietary office window towards the east end of the building. The dietary director went outside and met R3 who stated she must have gotten lost and was trying to find her way back into the building. Dietary director walked with R3 to the main entrance, sat outside for about 10 minutes, and returned inside the building.R3's progress note dated [DATE] at 8:58 p.m., identified R3 was agitated after supper because she could not go outside by herself due to the Wanderguard. Attempted to go outside twice and set the alarm off each time.R3's progress note dated [DATE] at 9:47 a.m., identified R3 was upset she could not go outside due to the Wanderguard and would not leave the front door so other residents and visitors could get in or out. At 10:47 a.m., R3 was placed on 15-minute checks due to refusing to put the Wanderguard back on. R3 continued to sit on the bench outside the front door.R3's Resident Safety Assessment for 15 minute checks began on [DATE] at 6:00 a.m., two pages that included 15-minute increments of time were provided. The second page, undated had done written across it beginning at 10:30 a.m. A handwritten note on the first page dated [DATE], identified R3 did not attempt to leave facility when outside. There was no indication R3 had a Wanderguard on at this time. R3's progress note dated [DATE] at 12:10 p.m., identified a wanderguard was placed on R3's left ankle. At 3:00 p.m., R3 was upset that the wanderguard was on and just wanted to sit outside. Activity staff sat outside with R3.R3's progress note dated [DATE] at 2:43 p.m., identified R3's family member requested the activity department put a schedule together as to when R3 could go outside with them.R3's physician dictation note dated [DATE], identified on [DATE], R3 was found outside the facility, and it was unclear how long she was outside, though it was believed to be under half an hour. R3 initially went outside to sit and then waked to the other side of the building, attempted to enter through a locked door, which led to some confusion. As a result a Wanderguard was applied. R3 stated when she gets near the door the alarm goes off and that is scary for her. R3's family member would like her to have a second chance at not wearing the Wanderguard. Plan included to continue wearing the Wanderguard and look into an assisted living facility that allows safe wandering outside, until that changes R3 will continue to need to wear the Wanderguard. BIMS 9, continues sundowning with wandering behavior, raising safety concerns. An order for dementia-ok for Wanderguard to ensure increased safety.R3's order communication form beginning date of [DATE], identified on [DATE]: see progress note, R3 found on east side of building not able to find entrance door back into facility. Wanderguard placed due to noted incident. Since Wanderguard placed resident cut off once and becomes upset related to having to wear it. R3 had zero knowledge of incident. Please advise if to continue Wanderguard. BIMS on [DATE] moderate impairment with a score of 9. Nurse Practitioner signed the order on [DATE].R3's Treatment Administration record dated 7/2025, identified to begin on [DATE], identified check to ensure Wanderguard is in place on left ankle and not expired every shift and test Wanderguard weekly to ensure working, test with tester.During an observation and interview on [DATE] at 9:50 a.m., RN-A stated last time she heard the door alarm go off was when R3 was trying to get out the door. R3 was observed at the main entrance door. A staff member was inside the nurses station pushed and held a button that appeared like a doorbell. R3 and an activity staff went outside and sat down. R3 just likes to sit outside on the bench.During an interview on [DATE] at 10:13 a.m., NA-B stated R3 feels like she does not need to be at the facility, she wants to be at home. We do not have 15-minute checks on R3 because she knows and follows directions.During a phone interview on [DATE] at 8:27 a.m., NA-A stated since R1 had eloped, NA-A liked to make sure where the residents with Wanderguards are at times and tried to keep them in the lobby so when she completed tasks she can quickly look to make sure the residents were still there.During an interview on [DATE] at 11:11 a.m., DON stated she has heard the alarm sounding on the doors when R3 attempts to exit. The facility did not do an elopement risk assessment on R3 because the facility does not have elopement risk assessments.The facility policy and procedure for missing resident reviewed [DATE], identified: Notify current staff of resident missing All staff to search all rooms, closets, etc. If unable to locate resident notify DON and social services Notify local police department-give police a copy of face sheet and picture of resident. Description of what resident is wearing. Additional information that would be helpful Notify family and/or legal guardian Social service and/or DON to follow up with vulnerable adult policy and procedureThe facility Missing Resident undated, identified Initial Actions printed at the top of the paper. The paper was divided in half with the first side blank and the side next to it identifying actions to be completed: Record the time that the resident was discovered missing and when and where he/she was last seen Verify the resident has not signed out or been discharged Perform census verification and resident roll call to determine if there are any other missing residents Activate facility's EOP (emergency operation plan) and appoint a facility Incident Commander if warranted Search the facility's grounds for the resident. If necessary, distribute copies of the residents photograph to staff searching the grounds. Keep a record of the areas searched. Be sure to check: closets, walk-in refrigerators/freezers, storage units, under beds and behind furniture If the missing resident is not found following an expedient search, call 9-1-1 and provide: name and description of missing resident, description of clothing, ambulation method, cognitive status, photo if available Notify responsible party/next of kin that resident is missing and search is underway Notify MN Department of Health to report an unusual occurrence and activation of facility's EOP Coordinate with public safety agencies in searching for the missing resident Once the resident is found, notify the responsible party/next of kin, facility staff, and public safety agency representativeThe facility Wander Management Transmitters User Guide dated 11/2018, identified it is the responsibility of the facility to establish and facilitate a regular inspection schedule for your system. It is recommended that a yearly inspection of the system by a qualified representative be completed for safety and performance. Failure to provide regular inspection of these products may result in equipment and/or system failure.System maintenance and testing it the responsibility of the facility to establish and facilitate a regular maintenance schedule for the system. This includes regular inspection, testing and cleaning. It is recommended to do monthly maintenance of the system and the facility keep records of maintenance and test completions. Failure to provide regular inspection of these products may result in equipment and/or system failure.Each transmitter is stamped with a warranty expiration date. Using a transmitter beyond the printed expiration date can result in system failure and/or elopement.When the CodeWatch is placed on a residents ankle, be sure to adjust the antennas at each door to a 4-5 foot range to the ankle. Failure to do so may allow a resident to elope because they will be closer to the door when the door detects their transmitter.All transmitters must be tested prior to use to verify proper operation, this includes every time the band is replaced.