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Any PRINTED version of this document is only accurate up to the date of printing 4-Apr-12. Saskatoon Health Region (SHR)

cannot guarantee the currency or accuracy of any printed policy. Always refer to the Policies and Procedures site for the

most current versions of documents in effect. SHR accepts no responsibility for use of this material by any person or

organization not associated with SHR. No part of this document may be reproduced in any form for publication without

permission of SHR.

1. PURPOSE

1.1 To identify patients whose safety would be jeopardized by leaving a nursing unit without

supervision.

2. POLICY

2.1 Assessment and advance identification of all patients at risk to wander will be made when

possible. (Advance identification may not be possible in all circumstances, for example, a

patient may experience a sudden change in behavior). Patients may be at risk of

wandering due to disorientation, confusion, restlessness, agitation, anxiety or any other

change in mental health status.

2.2 The wandering patient protocol will be instituted when the safety of a patient is jeopardized

by his/her potential absence from the unit or the hospital.

3. PROCEDURE

3.1 Patient at risk to wander

3.1.1 Ensure the patient is wearing a legible identification band.

3.1.2 Discuss patient’s assessment of being at risk to wander and management options

with the patient and family. Document discussion and Plan of Care in the Nursing

Progress Notes and Care Plan.

Note: It is important for the family to be cognizant of the fact that there is always a

balance between restraint and freedom and to be aware of the risks and

benefits associated with each state.

3.1.3 Complete Wandering Patient Identification sheet (appendix A) and place in the

patient care plan. Photocopy for Security.

Policies & Procedures

Title: WANDERING PATIENTS

- IDENTIFICATION OF

I.D. Number: 1151

Authorization

[x] SHR Nursing Practice Committee

Source: Nursing Affairs

Cross Index: EPP Manual code Yellow

Date Effective: June 2011

Scope: Saskatoon City Hospital

Royal University Hospital

St. Paul’s Hospital

Policies & Procedures: Wandering Patient-Identification of I.D. # 1151

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3.1.4 It is still a requirement to follow steps 3.1.1 - 3.1.3 when a security system is in place

(e.g. Wanderguard, Exi, Roamalert System, etc.)

3.1.5 Arrange for a digital picture of the patient to be taken.

3.1.5.1 Obtain consent from competent patient, family member/guardian (included

on Wandering Patient Identification Sheet)

3.1.5.2 Notify Security to take the picture. They will print two copies; one for the unit

and one for their records

3.1.5.3 Attach Patient ID label to back of photo

3.1.5.4 Attach first photo to patient’s Wandering Patient Identification sheet

(Appendix A) )to serve as reference for unit staff during a potential search.

Locate/place this form in the Patient Care Plan

3.1.5.5 Second photo will be attached to copy of Wandering Patient Identification

sheet, to be retained by Security

3.1.5.6 Notify Security when patient is discharged

3.1.5.7 All photo/identification will be placed in the confidential shredder box on

patient discharge

3.1.6 Document

3.1.6.1 Assessment process in the Nursing Progress notes

3.1.6.2 Patients potential to wander and nursing interventions in Patient’s Careplan

3.2 Code Yellow – Missing Patient (Refer to EPP Policy – Code Yellow Site or Unit-specific policy)

4. REFERENCES

(2007) Wandering in the Hospitalized Older Adult. Retrieved March 11, 2011 from

http://consultgerirn.org/searched?q=wandering+in+the+hospitalized+older+adult&Submit_searc

h.x=16&Submit_search.y=7

Evidence-Based Guideline: Wandering. Journal of Gerontological Nursing, Vol 36, No. 2, 2010.

Policies & Procedures: Wandering Patient-Identification of I.D. # 1151

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Appendix A