F0604

E

Unnecessary Wanderguard Use and Movement Restrictions on Cognitively Intact Resident

Albuquerque, New Mexico Survey Completed on 12-22-2025

Penalty

No penalty information released

Summary

The deficiency involves the use of a Wanderguard (elopement-prevention device) on a cognitively intact resident without adequate assessment, documentation, or evidence of unsafe wandering or elopement behaviors. Facility policies on elopement and wandering management state that elopement applies to residents with impaired cognition and/or poor safety awareness, and that residents will be assessed for elopement risk upon admission and at set intervals. The Wanderguard policy specifies that restraining an ambulatory resident simply to prevent wandering is unacceptable and that residents should feel allowed their freedom while under close observation. Despite these policies, the resident was placed on a Wanderguard, and the Medical Safety Device Assessment used for Wanderguard placement was documented as incomplete.

The resident’s records showed an admission date with diagnoses including Type 1 diabetes mellitus, anxiety disorder, major depressive disorder, and an initial diagnosis of dementia that was later questioned. A speech therapy discharge summary documented a MOCA score of 28/30, indicating no severe cognitive impairment, and prior cognitive functioning without need for supervision. A neuropsychological evaluation reported that dementia screening was negative, and the facility’s medical director agreed with a diagnosis of neurocognitive disorder but disagreed with the dementia diagnosis. The admission MDS documented a BIMS score of 15, indicating intact cognition, and no wandering behaviors exhibited. The resident’s care plan, however, labeled the resident as an elopement risk/wanderer related to a history of attempts to leave the facility unattended, called for monitoring location every 15 minutes, and documented use of a security bracelet related to poor safety awareness and forgetfulness associated with Type 1 diabetes, but did not include documented evidence of unsafe wandering or elopement attempts.

The resident repeatedly reported psychosocial distress related to the Wanderguard and movement restrictions. In complaint intake forms, the resident stated that the Wanderguard prevented leaving the unit to attend activities elsewhere on campus, caused feelings of isolation among residents with cognitive deficits, and contributed to depression and negative effects on mental health. The resident reported feeling like a “chained elephant in a cage” and expressed a desire for more rights and the ability to do enjoyable activities, including worship and socializing in the independent living area where the resident had previously lived. Staff interviews confirmed the resident’s emotional distress: the SSD and NP reported the resident cried, shook, and became upset about loss of independence and Wanderguard use, and an LPN stated the resident felt she was losing independence due to the device.

Facility staff provided varying accounts regarding the rationale for the Wanderguard. The DON stated the resident was assessed as a moderate elopement risk and that the Wanderguard was placed after this assessment, citing concerns about diabetic management, missed insulin doses, and inconsistent blood sugar monitoring, including an episode of blood sugar at 400 when the resident left without appropriate checks. The MD stated the Wanderguard was applied after two less restrictive safety measures failed, describing periods of clarity followed by behavioral escalation, removal of the device, attempts to leave to see the resident’s husband and dog, and aggressive behaviors, and characterized some unsupervised departures as elopement. However, the SSD stated she was unaware of any elopement attempts and confirmed the resident’s BIMS score of 15 with no cognitive concerns. The spouse reported that the resident was capable of independent activities in the area, believed the resident could leave the main building if staff were informed, and stated that after the resident left to attend to her dog and returned, the Wanderguard was placed. Despite the resident’s intact cognition and incomplete documentation of elopement risk and less restrictive interventions, the Wanderguard and associated movement restrictions remained in place, limiting the resident’s freedom of movement and contributing to psychosocial distress.