Failure to Ensure Wanderguard Function and Documentation for At-Risk Resident
Penalty
Summary
A dependent resident with severe cognitive impairment and a history of wandering was observed wearing a wanderguard bracelet on her right ankle. The resident was independently mobile, had diagnoses including dementia, and was assessed as being at risk for elopement. The care plan specified that the function and placement of the wanderguard sensor should be checked daily. However, there was no physician's order for the use of the wanderguard, and no documentation was found indicating that the placement or function of the wanderguard was checked between the beginning and end of the month. The MAR only reflected an order for the wanderguard starting late in the month, with checks not documented until several days after the order. Interviews with staff revealed a lack of awareness regarding the presence of residents with wanderguard bracelets, and staff confirmed that an order and regular checks should have been in place and documented. The facility's policy required that residents at risk for elopement have interventions such as a wanderguard applied, with nursing staff responsible for checking placement each shift and function daily, documenting these checks on the treatment record. These required checks and documentation were not completed as outlined in the policy.