Failure to Conduct Quarterly Wander Guard Assessments
Penalty
Summary
The facility failed to complete quarterly wander guard assessments for two residents, leading to a deficiency in ensuring a safe environment free from accident hazards. The facility's policy on Elopements and Wandering Residents requires that residents at risk for elopement receive adequate supervision and care according to their person-centered plan. However, the facility did not adhere to this policy, as evidenced by the lack of timely assessments for the residents involved. Resident R8, who has diagnoses of high blood pressure, arthritis, and diabetes, was last assessed for elopement risk on July 1, 2024, despite the requirement for quarterly assessments. Similarly, Resident R53, with diagnoses of high blood pressure, diabetes, and dementia, was last assessed on May 3, 2024. Both residents were supposed to wear wander guards, with checks on placement every shift and function checks daily on the night shift. The failure to conduct these assessments was confirmed by a registered nurse during an interview.
Plan Of Correction
R8 care plan was updated to indicate that she wants to keep wanderguard but it is not in activation status. Management will continue to approach resident regarding returning wanderguard. R53 care plans were updated to delete wanderguards. Elopement assessments updated. Updated assessments on all residents have been completed. R8's wanderguard will be de-activated as it is not needed, per assessment but she is not willing to surrender it. Like residents were audited to ensure no other care plans or wanderguards needed modifications. Education will be provided to the RNAC, Nurses and nursing management on wanderguard placement on or before 2/11/2025. Audits on wanderguards assessments be completed timely will be completed by the DON or designee weekly x 4 weeks and monthly x 1 month. Audit results will be reviewed through the monthly QAPI process/meeting.