Failure to Ensure Use of Wandering Device for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate supervision and ensure that a resident at high risk for elopement was wearing a required wandering device, as ordered by the physician and outlined in the care plan. The resident, who had severe cognitive impairment with a BIMS score of 4/15, a history of dementia, falls, and spinal fracture, was known to wander and exhibit exit-seeking behaviors. Staff interviews confirmed that the resident was supposed to wear a wander guard on the left ankle, which would trigger an alarm if the resident approached an exit. However, documentation in the Medication Administration Record (MAR) indicated that the resident was not wearing the device for six consecutive shifts prior to the incident. On the day of the incident, the resident was able to leave the facility unsupervised and without staff knowledge. The absence of the wandering device was confirmed by both staff and the resident's responsible party, who reported not seeing the device on the resident prior to the elopement. The resident was later found by law enforcement more than two miles from the facility, without the wandering device, and was returned to the facility. The facility's own policies required identification of residents at risk for wandering and implementation of safety interventions, including the use of a wander guard, but these were not followed in this case. Record reviews and staff interviews further revealed that nurses were expected to check and document the presence of the wandering device each shift, and to immediately replace it if missing. Despite these expectations, there was no documentation or action taken to ensure the device was in place during the period leading up to the resident's elopement. The failure to follow physician orders, care plan interventions, and facility policy directly led to the resident's unsupervised exit from the facility.