F0684

D

Failure to Manage Elopement Risk Assessments and Wander Guard Devices

Windsor Locks, Connecticut Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to complete timely elopement risk assessments and obtain a physician order for a wander guard device for one resident, and failure to timely replace and document monitoring for a malfunctioning wander guard device for another resident. One resident had diagnoses including dementia with behavior disturbances and depression, with a significant change MDS showing a BIMS score of 99, indicating severe cognitive impairment and inability to complete the interview. The MDS coded no wandering behaviors and no use of a wander/elopement alarm, while the resident’s care plan dated 12/16/2025 identified that the resident roamed into other residents’ rooms and directed staff to ensure the resident did not roam into rooms. Nursing notes indicated the resident had a wander guard in use during 2024, but the clinical record did not show when the wander guard was initiated or discontinued, and there was no physician order directing its use.

Further record review for this resident showed that no elopement risk assessments were completed from admission in 9/2024 through 2/18/2026. An elopement risk evaluation dated 2/19/2026 later identified that the resident ambulated independently, was cognitively impaired with poor decision-making skills, had a history of wandering into unsafe areas, and displayed behaviors that may indicate an attempt to leave the facility. The DON stated that elopement risk evaluations should be completed on admission, quarterly, and upon any readmission, and acknowledged that the assessments for this resident were not done as required. The DON also stated that if a wander guard is in use, there should be physician orders directing its use and documentation on the Medication Administration Record each shift and day it is functioning, which was not present in this case.

For the second resident, who had diagnoses including dementia, transient ischemic attacks, and syncope, the quarterly MDS showed a BIMS score of 6, indicating severe cognitive impairment, and documented daily use of a wander/elopement alarm. An elopement risk evaluation identified that this resident ambulated independently, was cognitively impaired with poor decision-making skills, and displayed behaviors that may indicate an attempt to leave. The care plan dated 1/22/2026 identified the resident as at risk for elopement and directed staff to check wander guard function and placement every shift and daily. A nursing note documented that the resident’s wander guard was in place but not functioning and that every 15‑minute checks were initiated; however, the wander guard was not replaced until two days later. The DON confirmed that the device malfunctioned, that staff did not have access to a replacement device at the time, and that there was no documentation of the every 15‑minute checks on the dates the device was not functioning, despite the facility’s documentation policy requiring accurate, timely, and complete nursing documentation reflective of the care provided.