Inaccurate Documentation of Wander Guard Use for Non-Ambulatory Resident
Penalty
Summary
The facility failed to ensure that the clinical record accurately reflected the care provided to a resident regarding the use of a wander guard device. The resident, who had multiple diagnoses including muscle weakness, seizures, aphasia, and was non-ambulatory and dependent on staff for all mobility and activities of daily living, was assessed as not being at risk for wandering or elopement. The resident's assessment documented that the wander guard was removed due to his inability to self-propel and lack of wandering behaviors. The care plan did not address wandering or elopement risk. Despite the removal of the wander guard, the electronic medical record (EMR) still contained an active physician's order to check the function of the wander guard daily, and nursing staff continued to initial on the Medication Administration Record (MAR) that this was being completed. Staff interviews confirmed that the resident did not have a wander guard and that the order should have been discontinued, but staff were unaware that the order remained active and continued to document its completion inaccurately. This resulted in a misrepresentation of the care being provided, contrary to facility policy requiring accurate and factual documentation.