Failure to Ensure Wanderguard Use for Resident with Wandering Risk
Penalty
Summary
A deficiency occurred when a resident with dementia and a history of wandering and exit-seeking behavior was not wearing a wanderguard bracelet as ordered. The resident's medical record included a physician's order for a wanderguard to be worn on the right ankle, with nursing staff required to check its placement every shift. Despite this, during an observation, the resident was seen without the wanderguard, even though the Medication Administration Record for that shift had been signed off by the nurse as if the device was in place. Staff present at the time confirmed the absence of the wanderguard and speculated that the resident may have removed it. The facility's policies on wandering and elopement, as well as on assistive devices, require identification of at-risk residents and the provision of safety interventions such as wanderguards. The Director of Nursing confirmed in an interview that the resident should always have the wanderguard on as ordered. The failure to ensure the resident was wearing the wanderguard as prescribed constituted a lapse in following safety protocols for residents at risk of wandering.