Failure to Document and Assess Use of Position Change Alarms and Lapses in Infection Control
Summary
A resident was admitted to the facility following hospitalization, with diagnoses including orthostatic hypotension, muscle weakness, and later, shingles. The resident was cognitively intact, able to use the call light, and could request assistance. Despite this, a position change alarm was observed in use for the resident, with no corresponding physician order, care plan intervention, or interdisciplinary assessment recommending its use. Documentation in the electronic medical record did not support the use of the alarm, and there was no evidence that less restrictive interventions were attempted prior to its implementation. Staff interviews revealed uncertainty about the process for determining alarm use, with CNAs indicating that alarms were often used for fall risk residents, sometimes at their own discretion, and without clear guidance or assessment documentation. The facility's policy required that alarms be used only in limited circumstances, based on individualized assessment, documented medical symptoms, and after considering less restrictive interventions. However, the resident's records lacked documentation of such assessments, orders, or care plan entries for the alarm. The DON confirmed that there was no documentation supporting the use of alarms for the resident and acknowledged the concern. The policy also required communication of interventions to all relevant staff, which was not evident in this case. Additionally, infection control deficiencies were observed. The resident was on contact precautions due to a diagnosis of shingles, with clear signage and physician orders requiring hand hygiene and the use of personal protective equipment (PPE) upon entering the room. A CNA was observed entering the resident's room without performing hand hygiene or donning PPE, touching the resident's environment, and improperly handling their face mask. The CNA was unaware of the correct reason for contact precautions and did not follow required infection control protocols, despite care plan and physician order instructions.
Penalty
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