Failure to Ensure Functioning Wander Guard Bracelet for Resident at Risk of Elopement
Penalty
Summary
A deficiency occurred when the facility failed to follow the care plan for a resident with severe cognitive impairment and a history of dementia, anxiety disorder, major depressive disorder, delusional disorder, and cognitive communication deficit. The resident was identified as being at risk for elopement, and the care plan specified that a wander guard bracelet should be worn and its proper functioning ensured. During an observation, it was found that the resident's wander guard bracelet was not functioning, as confirmed by the Unit Manager, who noted that the device did not respond and required replacement. Interviews with facility staff, including the Unit Manager, Administrator, COO, and Interim DON, revealed that the facility's policy required daily checks of wander guard bracelets to ensure they were working properly and that bracelets should be replaced if malfunctioning or if batteries were low. Despite these policies and care plan interventions, the non-functioning bracelet was not identified or replaced in a timely manner, resulting in a failure to provide adequate supervision and care as outlined in the resident's person-centered plan.