F0842

D

Failure to Document Wander Guard Use and Secured Unit Placement

Weslaco, Texas Survey Completed on 03-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident in accordance with accepted professional standards and its own Charting and Documentation policy. A female resident with liver cirrhosis, history of TIA, dementia, schizoaffective disorder, depression, anxiety, and hypertension had a severely impaired cognition score (BIMS of 4) and was identified on the MDS as having a wander/elopement alarm. On observation, a Wander Guard was noted on her right wrist, and staff, including an LVN and the DON, acknowledged awareness that the device was in place. However, record review showed no progress note or change in condition entry documenting when or why the Wander Guard was initiated, who placed it, or any associated assessment, despite the facility policy requiring documentation of changes in condition and procedures/treatments with date, time, provider, and assessment details.

The facility also failed to document the resident’s placement in a secured unit. An LVN assigned to the secured unit reported that the resident had been moved there the previous week because she experienced shortness of breath and required oxygen and closer monitoring, and stated that the DON handled the placement. The DON confirmed that the resident had been placed in the secured unit due to an episode of shortness of breath and the need for closer monitoring and more staff presence. Despite these changes in the resident’s status and location, the resident’s medical chart contained no progress note or change in condition entry reflecting the transfer to the secured unit, contrary to the facility’s policy that all nurses should update the medical record to reflect new conditions and changes in the resident’s status.