Failure to Complete Timely Elopement Risk Assessments and Obtain Wander Guard Function Orders
Penalty
Summary
The deficiency involves the facility’s failure to obtain and implement appropriate physician orders for wander guard function checks and to complete elopement risk assessments according to policy for residents with dementia and identified elopement risk. For one resident with dementia and moderate cognitive impairment, an elopement risk evaluation documented independent ambulation, poor decision-making, statements about leaving, and behaviors suggesting attempts to leave. The care plan identified a wander guard on the right ankle with interventions to redirect near exits and check device functioning per protocol, and physician orders directed staff to check wander guard placement every shift and function daily. However, review of elopement risk evaluations showed they were not completed at quarterly intervals as required, with gaps of 124 and 174 days between assessments, and the physician order for wander guard use was only reviewed during monthly order reviews. For another resident with dementia and severe cognitive impairment, the MDS and elopement risk evaluation identified cognitive impairment, behaviors suggesting attempts to leave, and use of a wander/elopement alarm. The care plan documented elopement risk with interventions to check wander guard placement and function every shift and daily. Record review showed that the admission elopement risk evaluation was followed by the next evaluation 179 days later, exceeding the quarterly requirement. Additionally, although there was a physician order to check wander guard placement every shift, there was no physician order directing staff to perform daily function checks of the wander guard. The DON confirmed that elopement risk evaluations are required on admission, quarterly, and at readmission, and that physician orders should direct daily function checks of wander guards, but acknowledged that the assessments were not completed timely and that an order for function checks was not obtained for this resident, contrary to facility policies on wandering risk assessment and wander-guard security system use.
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