Incomplete Documentation of Wander Guard Checks for Multiple Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records regarding the placement and function checks of wander guard devices for five residents with dementia and elopement risk. For one resident with severe cognitive impairment and documented room-roaming behavior, the care plan and elopement risk evaluation identified a need for a wander guard and shift-by-shift checks. A physician order directed staff to check the wander guard every shift, yet the MAR/TAR for February showed missing documentation of wander guard placement checks on specified evening and night shifts. A second resident with severe cognitive impairment, elopement risk, and a documented daily wander/elopement alarm had a care plan and physician order requiring wander guard function and placement checks every shift. However, the MAR/TAR from mid to late February contained multiple blank entries where staff failed to document these checks across several day, evening, and night shifts. A third resident with dementia and behavioral disturbances, identified as an elopement risk and care planned to use an alarm device with checks for proper functioning, also had a physician order for wander guard placement checks every shift. The February MAR/TAR showed missing documentation of these checks on two separate day shifts. A fourth resident with vascular dementia, Alzheimer’s disease, and severe cognitive impairment was assessed as an elopement risk and care planned to have a wander guard on the ankle with placement and function checks every shift, supported by a physician order. The February MAR/TAR showed blank entries for required wander guard checks on multiple shifts. A fifth resident with Alzheimer’s disease, severe cognitive impairment, daily wandering behaviors, and a history of wandering into unsafe areas had a care plan and physician order requiring wander guard checks every shift. The MAR/TAR from mid to late February showed missing documentation of wander guard placement checks on identified day and evening shifts. In an interview, the DON confirmed that it was the expectation that nursing staff document all provided care, including wander guard checks, acknowledged the missing documentation for all five residents, and referenced the facility’s documentation policy requiring accurate, timely, and complete nursing documentation of treatments.
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