Failure to Ensure Functioning Wander Guard Devices for Residents with Cognitive Impairment
Penalty
Summary
The facility failed to ensure that two residents with severe cognitive impairment received adequate supervision and functioning assistance devices to prevent incidents related to wandering and potential elopement. Both residents had diagnoses including unspecified dementia, psychotic disturbances, mood disturbances, and anxiety, with one also experiencing neuroleptic-induced Parkinsonism and chronic kidney disease. Documentation showed that both residents had orders for wander guard devices to be present and functioning on their lower extremities, with checks required every shift and specific instructions to test the devices at the front door to ensure alarms would sound. Despite these orders, observations revealed that neither resident's wander guard device was functioning properly at the time of survey. When tested at the front door, the devices did not activate the alarm, although the door alarm itself was operational. Staff interviews confirmed that checks for placement and functioning of the wander guards were documented as completed every shift, but the devices were not active during the survey. The ADON and maintenance staff stated that the system was checked regularly, and maintenance logs indicated that the system had passed recent checks. However, the handheld device used to activate or deactivate the wander guards was found to be inactive during the survey. Further review of records and interviews indicated that the facility had experienced previous issues with the wander guard system, including a recent repair to the front door alarm system. Despite staff and administrative claims that the system was functioning and that no residents had eloped, the direct observation of non-functioning wander guards for two residents with a history of exit-seeking behavior constituted a failure to provide adequate supervision and accident hazard prevention as required.