Failure to Ensure Bed Alarm Function and Accurate Fall Risk Assessment
Penalty
Summary
The facility failed to follow its fall prevention policy for a resident with a history of falls and multiple risk factors. The resident, who had diagnoses including unspecified thoracic vertebrae fractures, dementia, hypertension, osteoporosis, and a recent fall, experienced another fall resulting in a displaced proximal humerus fracture. Despite the care plan indicating the use of a bed alarm as an intervention, observations revealed that the bed alarm was not turned on or functioning. Staff interviews confirmed that the bed alarm was either not present or not operational, and the device was found disconnected from its sensor pad during inspection. Additionally, the facility did not accurately assess the resident's fall risk following the incident. The Fall Risk Assessment assigned a low-risk score, despite the resident's multiple predisposing conditions such as hypertension, osteoporosis, fractures, and a history of falls. Both the Director of Staff Development and the Director of Nursing acknowledged that the assessment was incorrect and that the resident should have been classified as high risk for falls based on her medical history and recent events. The facility's policies required staff to use devices like bed alarms as nursing interventions to prevent injury and to conduct thorough fall risk assessments considering all relevant diagnoses and recent incidents. However, the failure to ensure the bed alarm was functioning and the inaccurate fall risk assessment led to inadequate supervision and interventions for the resident, contrary to facility policy and procedure.