Failure to Document Wander Guard Placement per Professional Standards
Penalty
Summary
Nursing staff failed to consistently document the placement of a resident's wander guard bracelet on the Treatment Administration Record (TAR) as required by both facility policy and professional standards. Specifically, for one resident with diagnoses including diabetes, epilepsy, and major depressive disorder, there were blank documentation spaces on the TAR for several shifts, despite an active physician's order requiring the wander guard to be checked and documented every shift. The Director of Nursing confirmed that the expectation was for nurses to check the device and sign the TAR accordingly, but this was not done for the identified dates and shifts. The facility's policy on documentation emphasizes that if an action is not charted, it is considered not to have occurred. The deficiency was identified through interviews, medical record review, and examination of facility documentation, which showed that the required checks and documentation for the elopement device were not consistently performed or recorded. This failure was in direct violation of both the facility's own documentation guidelines and the standards set forth by the New Jersey Nurse Practice Act.