Failure to Complete Wander Assessment and Implement Wander Guard Orders for High-Risk Resident
Penalty
Summary
The facility failed to accurately complete a wander risk assessment and to ensure appropriate interventions and orders were in place for a resident with a known history of wandering and elopement risk. The resident, who had diagnoses including vascular dementia and anxiety disorder, was initially assessed as high risk for wandering prior to a hospital transfer. Upon readmission, the wander risk assessment was incomplete, with key sections left blank, resulting in an inaccurately low risk score. According to the facility's own assessment directions, the missing sections should have been completed and would have indicated a high risk for wandering. Additionally, after the resident's transfer to the hospital, all previous physician orders, including those for the use of a wander guard and checks for its placement and function, were discontinued. Upon readmission, although the care plan identified the resident as an elopement risk and included interventions such as the use of a wander guard, there was no documentation that a new physician order for the wander guard was obtained or that checks for placement and function were ordered or documented. The DON confirmed that the assessment was incomplete and that staff should have entered new orders for the wander guard but could not provide documentation that this was done. Facility policy required that residents identified as high risk for wandering have a wander guard applied, but the lack of a complete assessment and missing physician orders meant that this intervention was not properly implemented or documented. The deficiency was identified through review of clinical records, facility documentation, and staff interviews, which confirmed the failures in assessment completion, order initiation, and adherence to the plan of care for a resident at risk for wandering.