Failure to Monitor Wander Guard and Document Safety Checks for Wandering Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and ensure proper monitoring for a resident with severe cognitive impairment and a history of wandering. The resident was admitted with anxiety and a cognitive communication deficit, and an admission MDS documented a BIMs score of three, indicating severe cognitive impairment. A care plan dated 3/4/25 identified episodes of wandering and ordered a Wander Guard to be placed on the resident’s wheelchair, with interventions including checking the Wander Guard placement on every shift and using diversions such as activities, food, conversation, television, and books. A TAR initiated in 3/2025 instructed staff to check the Wander Guard placement on the left area of the wheelchair every shift. However, there was no documented evidence in the clinical record that staff were checking the Wander Guard to ensure it was functioning properly. On 3/6/25, an elopement occurred in which the resident was found approximately one block away from the facility next to a busy street. An Elopement Investigation Report identified the root cause as the resident’s confusion and a non-functioning Wander Guard. A former physical therapist assistant reported finding the resident very confused and in a precarious position near the busy street and stated that a CNA assisted in returning the resident to the facility. The CNA reported that the resident did not have a Wander Guard on the wheelchair at that time. Although the resident was placed on 15‑minute checks with a monitoring sign‑up sheet created, there was no documented evidence in the clinical record that staff conducted these 15‑minute checks following the elopement. The administrator confirmed that no 15‑minute monitoring sheets could be located and stated that it would be expected for staff to check Wander Guard placement and functionality.
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