F0689

D

Failure to Ensure Wanderguard Use and Required Census Checks for Elopement-Risk Resident

Hammond, Louisiana Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and follow physician orders for an elopement-risk resident. The resident was admitted with stroke, vascular dementia with behavioral disturbance, cognitive communication deficit, and Wernicke’s encephalopathy, and had a BIMS score of 8 indicating moderate cognitive impairment. The resident’s elopement risk evaluation documented that he was an elopement risk due to expressing a desire to go home, packing belongings, or staying near exit doors, and he had an active order to continue using a wanderguard. The care plan identified him as an elopement risk/wanderer who made statements about leaving, required a wanderguard, and needed cueing, reorientation, and supervision due to impaired cognitive status. Physician orders and the MAR specified wanderguard census checks every two hours.

On the day of the survey, review of the MAR showed that the ordered every-two-hour census checks were not completed for the 7:00 a.m. to 7:00 p.m. shift, with only one census check documented at 10:48 a.m. When observed at 2:07 p.m., the resident was fully dressed in bed, wearing shoes, without a wanderguard in place, and he stated he had removed the wanderguard about a month earlier and expressed a need to go home to mow the grass and grate his driveway. The wanderguard was found in the top drawer of his bedside table. The NP and DON both confirmed the resident had an order for a wanderguard due to elopement risk and that it was not in place as it should have been. The LPN assigned to the resident confirmed she was unaware the wanderguard was not on the resident, acknowledged she had only performed one census check during her shift, and confirmed she did not complete the ordered every-two-hour census checks.