Failure to Communicate Elopement Risk and Ensure Resident Identification
Penalty
Summary
The facility failed to ensure that services met professional standards of quality by not properly communicating a resident's high risk for elopement and by not ensuring the resident wore an identification (ID) wristband. A resident with significant cognitive impairment, including diagnoses of parkinsonism, major depressive disorder, dysphagia, and neurocognitive disorder with Lewy bodies, was admitted with orders for frequent monitoring and the use of a Wanderguard device due to elopement risk. Despite these orders, staff assigned to the resident were not formally notified of the elopement risk, and the resident was not included on the CNA assignment sheet. The CNA caring for the resident was unaware of the resident's risk status or the purpose of the Wanderguard, as this information was not communicated during shift handoff or morning huddle. Additionally, the resident was observed on multiple occasions without an ID wristband, contrary to facility policy requiring such identification for resident safety and proper administration of care. Staff interviews confirmed that the resident should have had an ID wristband and that the lack of communication regarding the resident's risk status and identification requirements contributed to the deficient practice. Facility policies reviewed indicated the necessity of both the Wanderguard system for elopement risk and the ID wristband for resident identification, but these were not consistently implemented for the resident in question.