Failure to Maintain Wanderguard and Supervision for Elopement-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and use of assistance devices to prevent accidents for one resident identified as an elopement risk. The resident had diagnoses including altered mental status, history of falling, alcohol dependence with withdrawal delirium, age-related physical debility, and metabolic encephalopathy, and an MDS BIMS score of 00 indicating severe cognitive impairment. The baseline care plan identified the resident as at risk for elopement related to wandering and specified interventions including a Wanderguard on the right wrist and redirection from doors. Facility policies on elopement and accidents/supervision required elopement risk assessment at admission, development of an elopement prevention care plan, use of an alarm system to notify staff when exit doors are opened, and implementation of specific interventions to reduce risk from environmental hazards, including adequate supervision. On the survey date, the NHA identified the resident as one of two residents using the Wanderguard system, but the surveyor observed the resident alone in a wheelchair without any Wanderguard device in place and speaking incoherently about needing to meet family. A CNA confirmed the resident was supposed to always have a Wanderguard but could not locate it, and an RN then placed a Wanderguard on the resident’s ankle, stating the resident had fallen the previous night and been sent to the ED, with no ability to determine how long the resident had been without the device. The surveyor later observed the resident independently exit the room at a fast walk, cross the hall, and enter another resident’s room without a chair alarm in place, requiring immediate staff intervention and redirection. Record review showed prior documentation of wandering and attempts to go through doors looking for beer, with a Wanderguard previously placed due to elopement risk, but there was no documentation regarding whether the Wanderguard was in place before or after the fall and ED visit, no documentation of assessment upon return, and no CNA or nursing documentation of routine monitoring to ensure the Wanderguard was in place. Staff interviews indicated reliance on a binder listing residents requiring Wanderguards and a shared responsibility among all staff interacting with the resident to ensure the device was in place.
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