Care Plans Lacked Documentation of Wander Guard Interventions
Penalty
Summary
The facility failed to ensure that the care plans for three out of four residents included documentation of services provided, specifically the use of wander guards. For one resident with severe cognitive impairment and a history of exit-seeking behavior, the care plan did not document the presence of a wander guard, despite physician orders and progress notes indicating its use. This resident had diagnoses including unspecified dementia, psychotic and mood disturbances, anxiety, hypertension, hypothyroidism, edema, and psychotic disorders with hallucinations and delusions due to physiological conditions. The resident's progress notes reflected active exit-seeking behavior, and orders were in place for a wander guard to be checked every 10 hours, but this intervention was not reflected in the care plan. Another resident, also with severe cognitive impairment and daily wandering behavior, had similar omissions. This resident's diagnoses included unspecified dementia, psychotic and mood disturbances, anxiety, sequelae of cerebral infarction, neuroleptic-induced Parkinsonism, chronic kidney disease stage 4, hypertension, anemia, cognitive communication deficit, difficulty in walking, and schizoaffective disorder. Despite daily wandering and an order for a wander guard, the care plan did not document this intervention. Progress notes indicated active exit-seeking behavior, but the care plan failed to reflect the use of the wander guard as an intervention. A third resident, with moderate cognitive impairment and no documented wandering behavior, also had an order for a wander guard, but the care plan did not include this intervention. Diagnoses for this resident included unspecified dementia, psychotic and mood disturbances, anxiety, hypothyroidism, difficulty in walking, generalized muscle weakness, and unspecified pain. The care plan lacked documentation of the wander guard, even though orders were in place for its use. Interviews with facility staff confirmed that the care plans were not updated to reflect the use of wander guards for these residents.