Failure to Ensure Consistent Monitoring of Elopement Device Function
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents, specifically regarding the monitoring of an elopement device. The resident in question had multiple diagnoses, including cerebral infarction, intracerebral hemorrhage, psychosis, mood disorder, substance abuse, anxiety disorder, personality disorder, and encephalopathy. Although there was a physician's order to check the placement and location of the wander device, there was no order or documentation in the treatment authorization request (TAR) to check the function of the device. The facility's Elopement/Unsafe Wandering Policy and Procedure did not address monitoring the function of the elopement device. Interviews with nursing staff and facility leadership revealed inconsistent knowledge and practices regarding how and how often to check the function of the wander device. Some staff were unaware of the correct procedure or equipment to use, while others provided varying answers about the frequency of checks, ranging from every shift to daily or only on the night shift. The Director of Nursing stated that all nurses should know how to check the function of the device and that it should be done every shift, but this was not reflected in staff responses or in facility policy. This lack of clear guidance and consistent practice led to the deficiency in ensuring the resident's safety from accident hazards.