Failure to Maintain Functioning Wanderguard System for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide a functioning assistance device for supervision to prevent accidents for a resident with severe cognitive impairment. The resident, who had diagnoses including unspecified psychosis, unspecified dementia, and schizophrenia, was assessed as severely cognitively impaired and required a wander/elopement alarm daily. Physician orders specified that the resident should have a Wanderguard bracelet checked every shift to ensure it was functioning and in place. However, no elopement risk assessment was completed for the resident. On multiple occasions, it was observed that the Wanderguard alarm did not sound when the resident exited a door with staff. Staff interviews confirmed that the resident frequently wandered and required the Wanderguard for safety, and that the malfunction had been reported to nursing leadership. The system had not been tested since a staff member responsible for testing was on leave, and facility leadership confirmed that elopement risk assessments were not conducted. The Wanderguard system was expected to alert staff if a resident exited the building, but it was not functioning as required.