F0842

D

Incomplete and Inaccurate Documentation of Wander Guard Use and Resident Rounds

Windsor Locks, Connecticut Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate clinical records related to resident wandering risks, care checks, and wander guard devices. For one resident with dementia and identified elopement risk, the MDS documented no wander/elopement alarm despite physician orders and a care plan indicating use of a wander guard and the need to check its placement every shift and function daily. MAR/TAR review for this resident showed missing documentation by nursing staff on multiple dates for both wander guard function and placement checks. A reportable event documented that this resident, who had dementia and a history of wandering, was found outside the building early in the morning and was brought back inside, assessed, and later pronounced deceased by EMTs.

Nurse aide care check rounds documentation and the aide’s written statement indicated that this resident was observed asleep in bed at approximately 1:00 AM and again around 3:00–3:30 AM, with the aide also documenting care to the roommate at 3:30 AM. However, video obtained by local police showed a person believed to be this resident outside at the back of the building at 1:50 AM, walking along the side of the building and appearing at the driveway apron at 1:55 AM, which conflicted with the aide’s documentation that the resident was in bed at 3:00 AM. The video also showed staff locating the resident on the sidewalk in front of the building at 5:11 AM. The discrepancy between the video evidence and the aide’s charted observations demonstrated that the resident location rounds documentation was not accurate.

Two additional residents with dementia and significant cognitive impairment, both assessed as having wandering or elopement risk, also had incomplete documentation related to their wander guard devices. For one resident with daily wandering behaviors and a care plan directing wander guard checks every shift and as needed, MAR/TAR review showed missing nurse documentation on several dates for both function and placement checks. For another resident with severe cognitive impairment and a care plan directing wander guard function and placement checks every shift and daily, the MAR/TAR showed missed documentation of placement checks by two LPNs, and there was no physician order on file to monitor wander guard placement every shift and function daily. The DON stated it was her expectation that nursing staff document all care provided, acknowledged that the documentation for these residents was incomplete or missing, and that orders should be obtained for all residents to check wander guard placement every shift and function daily. A facility documentation policy stated that nursing documentation will be accurate, timely, complete, and reflective of the care provided.