Failure to Document Ordered Wanderguard Checks for Elopement-Risk Resident
Penalty
Summary
Facility staff failed to document ordered interventions intended to prevent elopement for a resident with a known history and risk of elopement. The resident, who had intact cognition per a recent MDS but diagnoses including diabetes with mononeuropathy, schizoaffective disorder, bipolar disorder with psychotic features, muscle weakness, and difficulty walking, was assessed as at risk for elopement on an Elopement Risk Review that noted verbalized desire or plans to leave without authorization, cognitive impairment, decreased safety awareness, and disturbances in judgment or history/risk of wandering. The resident’s care plan identified elopement risk related to attempts to leave the facility and a prior incident, and included use of a wanderguard tag as an intervention. Physician orders directed staff to check placement of the wanderguard every shift, check skin integrity under the wanderguard on the left ankle every shift, and check skin integrity, function, placement, and expiration of the wanderguard every shift, replacing it immediately if expired, in ill repair, or not functioning. Review of the Treatment Administration Record revealed blank boxes for these wanderguard-related orders on the night shift of a specified date, indicating no documented checks were performed that shift. Progress notes for that period documented that a police officer informed nursing staff that the resident had been picked up by a passerby on a nearby road, taken to a convenience store for coffee, and then returned to the facility by another officer; the resident stated they knew the code to the facility door and refused to further discuss the elopement. The progress notes contained no documentation that skin integrity, placement, or function of the wanderguard were checked. A facility document regarding timely and accurate MAR/TAR documentation, signed by the LPN assigned that night, emphasized that all entries must be signed promptly and accurately and that records should be reviewed for completeness at the end of the shift. The DON confirmed that the wanderguard should have been checked every eight hours and that blank spaces on the TAR meant there was no way to know if the care was provided, stating that if nurses did not document something, it did not happen.
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