Failure to Notify POA of Wander Guard Placement and New Orders
Penalty
Summary
The facility failed to notify the representatives or Power of Attorney (POA) for two residents when a new physician's order was implemented and a wander guard device was placed on each resident. For one resident with severe cognitive impairment and diagnoses including dementia and Alzheimer's disease, a wander guard was ordered and applied due to elopement risk, but there was no documentation of notification to the resident's POA. The POA later confirmed he was unaware of the device placement and had not been notified by the facility. For another resident with moderate cognitive impairment and diagnoses of mild intellectual disabilities, major depressive disorder, and generalized anxiety, a wander guard was also ordered and applied after an incident of attempted elopement. The resident's POA only learned of the device from the resident, not from facility staff, and there was no documentation of notification in the records. Staff interviews confirmed that the responsible LPN did not notify the residents' representatives or POAs about the new orders or the application of the wander guards. The DON and Administrator both acknowledged that there was no documentation of such notifications and that the facility did not have a policy in place for notifying family or POA of changes in condition, new orders, or the application of a wander guard. The facility census at the time was 42 residents, and the deficiency was identified through EHR review, observation, document review, and interviews with staff and family.