Failure to Obtain Proper Authorization for Bed Pad Alarm Use
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints without proper authorization and documentation. Specifically, the facility did not obtain a physician's order, informed consent, or conduct a device use or restraint assessment for the use of a bed pad alarm for a resident. The resident, who had been admitted with diagnoses including end-stage renal disease and generalized muscle weakness, was observed with a bed alarm in place without the necessary documentation and assessments. The resident's medical records, including the Minimum Data Set, indicated that the resident had intact cognition and the ability to make medical decisions. Despite this, the facility did not have a care plan that included the use of the bed pad alarm as an intervention for fall risk, even though the resident was identified as high risk for falls. Observations confirmed the presence of the bed alarm, and interviews with staff revealed a lack of awareness regarding the necessary physician's order and informed consent. The Director of Nursing and Assistant Director of Nursing acknowledged the oversight, confirming that the required assessments, orders, and consents were not completed prior to the use of the bed pad alarm. The facility's policies on informed consent and physical restraints were not followed, which require a physician's order, informed consent, and a care plan for the use of any physical restraint. This deficiency placed the resident at risk for restricted freedom of movement and other potential harms.
Plan Of Correction
C. What measures will be put into place or what systematic changes the facility make to ensure that the deficient practice does not recur; The Director of Staff Development will re-educate licensed nurses and the IDT on the facility's Physical Restraints policy with emphasis on verifying informed consent, obtaining a physician order, developing a care plan and completing a device/restraint assessment for the use of devices having the potential to become an unnecessary restraint on or before, 3/20/2025. The DSD orients new employees upon hire, annually, and as needed on the facility's Restraint policy and procedure including verifying informed consent, care planning, physician order and assessments for use of devices. The Director of Medical Records will audit the orders of residents' devices to ensure there is documented verification informed consent, care planning, device/restraint assessment and physician order are present in the record. Results of the audit will be provided by the physician; and provide completed audits to the Director of Nursing for tracking and trending analysis and further follow through as needed. D. How the facility plans to monitor its performance to make sure solutions are sustained; The Director of Staff Development will monitor the completion of staff training during new hire orientation, and as needed on the facility's devices and restraints procedures, including verification of informed consent, care planning, physician order and assessment for use of bed/pad alarms. The Director of Nurses will monitor the Medical Records device and restraint audit to ensure all required components have been completed to identify variance to standard concerns and maintain compliance with this plan of correction. The Director of Nursing/designee will report significant trends identified to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee recommended interventions to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025 F 604 F 604 F640 Accuracy of Assessments CFR(s): 483.20(g) A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident 126's discharge assessment was transmitted 2/25/2025 and accepted into the QIES system on 2/25/2025. The Nurse Consultant/designee re-educated the MDS Nurse re: Transmitting Resident Assessments Timely on 3/24/2025. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken; The MDS Nurse completed an audit of resident discharge assessments 1/1/2025 through 3/01/2025 to ensure resident discharge assessments were completed and submitted as required by the RAI. All other resident discharge assessment locations were coded accurately. No other residents were identified as affected by the facility practice. C. What measures will be put into place or what systematic changes the facility make to ensure that the deficient practice does not recur; The MDS Consultant/designee will re-educate the MDS Nurse and MDS