Failure to Complete Wander Risk Evaluations per Policy for Residents with Cognitive Impairment
Penalty
Summary
The deficiency involves the facility’s failure to complete Wander Risk Evaluations according to its own policies for two residents with dementia and cognitive impairment. One resident with vascular dementia, substance dependence, generalized anxiety disorder, depressive episodes, and a history of traumatic brain injury had a Wander Risk Evaluation completed on 2/4/25 that identified a low risk for wandering, with no further Wander Risk Evaluations documented from 2/5/25 through 2/27/26. A quarterly MDS showed moderately impaired cognition and independence with mobility, and the resident’s care plan identified impaired cognitive function/dementia, poor impulse control, history of altercations, psychoactive drug use, fall risk, history of alcohol abuse, and risk for disorientation and confusion, with interventions including every 15‑minute monitoring. A nurse’s note documented that on 1/23/26 the resident expressed a desire to leave the facility and was placed on every 15‑minute checks, but no new Wander Risk Evaluation was completed at that time. The second resident had dementia without behavioral disturbances, altered mental status, a history of falls, and a physician’s order for a Wanderguard on the right wrist with placement and function checks every shift. A Wander Risk Evaluation dated 11/12/25 identified a low risk for wandering/elopement but was incomplete, with only one of eight questions answered, and no subsequent Wander Risk Evaluations were found in the clinical record. A quarterly MDS identified severely impaired cognition and memory problems, and the care plan documented that the resident was at risk for wandering and/or elopement with an intervention for a Wanderguard on the right wrist. Facility policies required elopement/wander risk evaluations on admission, readmission, quarterly, annually, and with significant changes in condition, and ongoing assessment for elopement and unsafe wandering throughout the stay. The DON confirmed that Wander Risk Evaluations should be completed in their entirety at least quarterly and acknowledged that required evaluations were not completed for these residents.
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