Failure to Ensure Staff Competency and Monitoring of Wander Guard Alarm System
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed the necessary education and competencies to monitor and verify the functionality of the wander guard alarm system for residents at risk of wandering and elopement. Multiple staff interviews revealed a lack of clarity regarding who was responsible for checking the wander guard devices and exit door alarms, as well as how often these checks should occur. Staff members were unaware that not all exit doors were equipped with the alarm system, and there was no consistent process in place for verifying device or door functionality. Documentation confirming daily or shift-based checks, as required by facility policy and resident care plans, was not available during the survey. Care plan reviews for six residents identified as being at risk for wandering or elopement indicated that their wander guard devices were to be checked every shift to ensure proper function. However, the facility was not using the manufacturer's device to verify the functionality of the wander guard system for either residents or doors. The facility's elopement policy required daily checks of door keypads and nightly checks of monitoring devices, but these procedures were not being followed or documented. This lack of adherence to policy and insufficient staff education led to a deficiency in ensuring the safety and well-being of residents with elopement risks.