Failure to Follow Physician Orders for Wanderguard and Fall Prevention Devices
Penalty
Summary
Two deficiencies were identified involving the care and services provided to two residents. For one resident with a diagnosis of dementia, there was a physician's order for a wanderguard device to be placed on the right wrist, with instructions to check the battery daily and the placement every shift. However, during observation, the resident was found without the wanderguard device on either wrist or wheelchair. Staff interviews confirmed the absence of the device, despite active orders and a history of the resident attempting to leave the unit. Additionally, the elopement risk assessment was not completed prior to the initial placement of the wanderguard, contrary to facility policy, which requires such assessments upon admission, change of condition, and annually. For another resident with a history of cerebral infarction and muscle weakness, and identified as high risk for falls, physician's orders specified that floor mats should be placed on both sides of the bed. During observation, only one mat was in place, while the other was found rolled up and not in use. Staff confirmed that both mats should have been positioned on the floor as a precautionary measure, in accordance with the resident's care plan and physician's orders. The facility's policy requires licensed nurses to implement physician orders, which was not followed in this instance. These findings were based on direct observation, staff interviews, and review of medical records and facility policies. The failures to follow physician orders and facility protocols had the potential to adversely affect the physical and psychosocial well-being of the residents involved.