Deficiencies in Wander Guard Management and Medication Reconciliation
Penalty
Summary
The facility failed to ensure that residents were provided with appropriate treatment and care by not having physician orders, individualized care plans, and accurate assessments for the use of wander guards for four residents. Specifically, one resident did not have any physician orders for a wander guard despite multiple elopement evaluations indicating no risk, while another resident had orders for a security guard but lacked orders to check the wander guard battery weekly. Additionally, care plans for two residents identified a risk for wandering or elopement but did not include interventions to check the wander guard battery weekly, and physician orders for these residents also omitted this requirement. The Director of Nursing confirmed these omissions and inconsistencies during interviews, and acknowledged that once a resident is identified as an elopement risk, they should remain so unless discharged or bedbound. Another deficiency was identified in the medication reconciliation process upon admission. One resident, who had diagnoses including heart failure, diabetes, and end stage renal disease, was prescribed Calcium Acetate at a specific dose upon discharge from an acute care setting. However, the medication was transcribed incorrectly upon admission to the facility, resulting in the resident receiving only half the prescribed dose. The Certified Registered Nurse Practitioner confirmed that this was a transcription error and that the resident had been receiving the incorrect dose since admission. These findings were based on a review of facility policies, clinical records, and staff interviews. The deficiencies were confirmed by both the Director of Nursing and the Nursing Home Administrator, who acknowledged the lack of appropriate physician orders, care plan interventions, and accurate medication transcription for the affected residents.