Failure to Assess, Document, and Obtain Consent for Wander Guard Use
Penalty
Summary
The facility failed to properly assess and document the need for a Wander Guard alarm for a resident with chronic obstructive pulmonary disease and severe cognitive impairment. The resident was admitted with a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment, but the most recent elopement risk evaluation documented the resident as not at risk for elopement. Despite this, the care plan identified the resident as an elopement risk and included the use of a Wander Guard device. The device was observed attached to the resident's left ankle, and staff confirmed its use. Interviews with facility staff revealed that there was no written consent or physician's order for the use of the Wander Guard, and no updated elopement risk assessment had been completed to justify its use. The Social Service Director had obtained only verbal consent from the resident's power of attorney after discussing the resident's behavior, but no written documentation of consent was present. The Interim Director of Nursing confirmed the absence of both a physician's order and written consent, as well as the lack of an updated risk assessment supporting the intervention.