Failure to Implement Bed Alarm as Care Planned for Fall Prevention
Penalty
Summary
The facility failed to implement a person-centered care plan for one resident by not ensuring that the resident's bed alarm was functioning as indicated in the care plan for fall prevention. The resident, who had a history of falls, unspecified dementia, and a recent fracture of the thoracic vertebrae, was admitted with a care plan intervention requiring a bed alarm while in bed. The care plan was reviewed and agreed upon by the resident's family member and the interdisciplinary team. However, during observation, the resident was able to move in bed without the bed alarm sounding, and both the resident and staff confirmed that the bed alarm was not in use or functioning at that time. Further investigation revealed that the bed alarm device was present but not turned on, and the sensor pad was not connected to the alarm machine. Staff interviews confirmed that the bed alarm should have been checked and ensured to be operational as part of the resident's care plan. The facility's policy emphasized the importance of individualized care plans and the responsibility of staff to implement interventions as designed. The failure to follow the care plan placed the resident at risk for falls and injury.