Failure to Obtain Informed Consent for Chair Alarm Use
Penalty
Summary
The facility failed to promote and facilitate resident self-determination for a resident by not obtaining informed consent before initiating a chair alarm. The resident, who had diagnoses including repeated falls and generalized muscle weakness, was observed with a chair alarm without documented evidence of consent. The facility's policies required that residents be informed and have the right to refuse such interventions, but there was no documentation of discussions with the resident or their representative regarding the alarm's use. The resident expressed discomfort with the chair alarm, stating it was bothersome and that they had never fallen from the chair. They also mentioned that the alarm was loud and took a long time for staff to respond to. Interviews with facility staff revealed that the alarms were often initiated on admission as a precaution for high-risk residents, but the ongoing need for the alarm had not been reevaluated since the resident's admission. Staff acknowledged that unnecessary alarms could be undignified and that residents had the right to fall. The Director of Nursing stated that alarm use was determined on admission and reassessed during care plan meetings. However, the resident was not documented as present at their care plan meeting, and there was no evidence that the use of the alarm was discussed with them. The facility's failure to obtain informed consent and properly document the resident's preferences and needs led to the deficiency.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F561- Self-determination: Crouse Community Center will ensure that the facility is promoting and facilitating resident self-determination through support of resident choice, focusing on significant aspects of his/her life in the facility. Corrective action: Resident #4 was re-interviewed by Nurse Manager and declined the use of alarms. Alarms were discontinued and Care plan and CNA notification sheet updated on (MONTH) 10, 2025. Other residents: All residents in the facility were reviewed for fall risk. If alarm use is determined to be an appropriate fall alert intervention, consent forms will be completed by resident or designated representative and comprehensive care plan will be implemented. Systemic changes: The facility will promote self-determination with focus on alarm use and resident choice. Consent forms were created and all staff educated on obtaining consent prior to alarm use. Monitoring: Audits will be conducted by Director of Nursing to include Alarm use and Care planning. This will be done by checking physician orders [REDACTED]. This audit will be done monthly with 100% compliant threshold and reported monthly to QAPI. Responsible Party: Director of Nursing