Failure to Monitor Wander Guard and Inadequate Pain Management Documentation
Penalty
Summary
The facility failed to monitor and document the use of a wander guard device according to professional standards for a resident assessed at risk for wandering. The resident, who had diagnoses including traumatic subarachnoid hemorrhage, dementia, and depression, was identified as severely cognitively impaired and exhibited wandering behaviors. Although the care plan and facility policy required daily checks for the placement and function of the wander guard, as well as skin checks for irritation, documentation was inconsistent. Clinical records showed alternating documentation of the device being present or absent on various days, and there was no evidence of daily checks or skin assessments as required. The Director of Clinical Excellence confirmed that the physician's order for the wander guard was not obtained in a timely manner and that documentation was inaccurate, with no evidence of adherence to policy or care plan interventions. The facility also failed to provide care and services consistent with professional standards for pain management for another resident with a history of fractures and malignancy, who was cognitively intact and reported frequent pain. The care plan included interventions for pain assessment and medication administration, but physician orders for both opioid (Tramadol) and non-opioid (Tylenol) pain medications lacked specific parameters for use. Nursing staff administered PRN Tramadol on most days, sometimes multiple times per day, and also administered Tylenol for similar pain scores, without clear guidance on which medication to use for specific pain levels. Documentation did not include non-pharmacological interventions prior to opioid administration, and the care plan did not address the use of opioid medication. Interviews with the Director of Clinical Excellence confirmed that the facility did not clarify physician orders for pain medications, did not document non-pharmacological interventions prior to opioid use, and did not follow facility policy or accepted standards of practice for pain management. The lack of clear parameters for medication administration and incomplete documentation contributed to the deficiencies identified in the management of both the wander guard device and pain control.