F0689

D

Failure to Complete Elopement Safety Checks and Wander Guard Monitoring

Watertown, New York Survey Completed on 03-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and complete required safety checks for a resident at high risk for elopement. The resident had dementia with moderately impaired cognition, could ambulate independently with a walker, and used an elopement alarm daily. An elopement risk assessment identified the resident as high risk, and the comprehensive care plan included interventions such as checking the placement and function of the wander guard every shift. Facility policies required that residents on increased supervision receive visual checks at specified 30- or 60-minute intervals, that these interventions be reflected in the care plan and resident care instructions, and that wander guard devices be checked each shift for proper function and documented accordingly.

On one incident date, the resident had been placed on 30-minute safety checks following a prior elopement risk assessment and a nurse’s progress note documenting initiation of 30-minute checks. However, there was no evidence that these 30-minute checks were added to the comprehensive care plan. The resident was last seen in bed at 2:00 AM and was later found in the basement lobby around 5:00 AM after the wander guard system alarmed. The safety check form for that date showed that 30-minute checks were not documented from midnight through mid-afternoon, leaving large undocumented intervals despite staff statements that the resident was on 30-minute or 60-minute checks at the time. Interviews with the RN unit manager and DON confirmed that the checks should have been on the care plan and resident care instructions and that the safety check sheet should not have been blank, but there was no process in place to monitor completion of these forms.

In a later review period, the resident remained identified as high risk for elopement, with the care plan and physician orders directing that the wander guard on the right ankle be checked every shift and that 60-minute safety checks continue. March safety check forms showed multiple dates where hourly checks were not signed, indicating missed or undocumented safety checks. The MAR showed that an LPN signed for wander guard checks for this resident on a specific day, but in interview the LPN admitted they had not actually performed all the checks and instead relied on aides to report issues, citing workload. Multiple staff, including CNAs, LPNs, the RN unit manager, and the DON, acknowledged that safety checks and wander guard checks were required, that there should be no blanks on the safety check sheets, and that nurses should not sign for checks they did not perform. They also confirmed there was no consistent follow-up or monitoring process to ensure completion and accuracy of the safety check documentation.