F0689

D

Failure to Maintain Elopement Protection and Safe Transfer Practices

Minocqua, Wisconsin Survey Completed on 01-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and assistive devices for two residents. One resident with anxiety, depression, dementia, and severe cognitive impairment (BIMS 5/15) had been assessed as an elopement risk and care planned to wear a wanderguard on the left wrist, with orders and TAR documentation indicating staff were to check the device’s placement, function, and the skin around it every shift. The elopement assessment, care plan, and elopement binder all identified this resident as an elopement risk with a wanderguard in place. However, during surveyor observations and interviews on the same day, the resident was repeatedly observed without a wanderguard on the left wrist, left ankle, body, or wheelchair. Despite this, nursing documentation reflected that the wanderguard was being checked, and staff interviews showed uncertainty about whether the resident had a wanderguard on, with one CNA reporting that when taking the resident outside to smoke, no alarm had ever sounded.

The second example concerns a resident with moderately impaired cognition (BIMS 5) who required substantial/maximal assistance for toilet transfers and had a care plan specifying a two‑person transfer with a gait belt. A surveyor observed this resident sitting on the toilet under the supervision of a CNA, with no gait belt in place. The CNA then performed incontinence care and transferred the resident independently to a wheelchair without using a gait belt. When questioned, the CNA stated that they had not been using a gait belt for this resident’s transfers and, after checking the care plan, stated that it did not indicate the need for a gait belt, despite the documented care plan approach requiring one.