Failure to Accurately Monitor and Document Elopement Prevention Device
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's medical records were complete and accurately documented regarding the monitoring of an elopement prevention device, specifically a TekTone device. The facility's policy required that the bracelet be checked each shift and documented in the treatment record. However, a physician's order to check the device every shift was incorrectly transcribed to be completed only once weekly, and documentation showed that the last check occurred three days prior to the resident's elopement. There was no evidence that the device was checked as ordered, and the resident was found outside the facility without the device, having sustained injuries including a large hematoma and a hip fracture. The resident involved had a history of dementia, cognitive decline, and severe cognitive impairment, and was identified as being at risk for wandering and elopement. The care plan included interventions such as frequent visual checks and redirecting the resident away from exits. Despite these interventions, the failure to accurately transcribe and implement the physician's order for device monitoring led to the resident's unsupervised exit from the facility and subsequent injury. Staff interviews confirmed the device was not on the resident at the time of the incident, and the order transcription error was acknowledged by the Director of Nursing Services.