Failure to Develop and Implement Care Plans for Bed Pad Alarm Use in High Fall Risk Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents who were both identified as high fall risks and were observed using bed pad alarms. Both residents had severe cognitive impairment and required substantial to maximal assistance with activities of daily living, as documented in their Minimum Data Set assessments. Despite their high risk for falls, as indicated in their respective Fall Risk Assessments, there was no care plan in place addressing the use of bed pad alarms for either resident. Observations confirmed that both residents were using bed sensor pads connected to alarm monitors, and interviews with nursing staff verified that the alarms were in use due to the residents' high fall risk. However, review of the care plans by the Infection Preventionist revealed that neither resident had a care plan that included interventions or measurable objectives related to the use of bed pad alarms. This lack of care planning was contrary to the facility's own policy, which requires comprehensive, person-centered care plans with measurable objectives and timetables for each resident.