Failure to Document Wander Guard Trial for High-Risk Resident
Penalty
Summary
Licensed Vocational Nurse 1 (LVN 1) failed to document a wander guard trial for one resident in the medical record, as required by the facility's Charting and Documentation policy. The resident, who had a history of cerebral infarction, cognitive communication deficit, and was assessed as a high fall risk due to confusion, balance problems, and use of antihypertensive medication, was admitted with multiple care interventions in place to prevent falls. Despite these risks and the use of a wander guard device, LVN 1 did not record the trial in the resident's medical record during assigned shifts. This omission was confirmed during interviews with LVN 1 and the Director of Nursing (DON), both of whom acknowledged that documentation and staff endorsement of the wander guard trial should have occurred according to facility policy. The lack of documentation resulted in incomplete medical records for the resident and created a risk of miscommunication among the interdisciplinary team regarding the resident's condition and response to care.