Failure to Develop Policy and Monitor Use of Sensor Alarm Pads
Penalty
Summary
The facility failed to develop and implement a policy for the use of sensor alarm pads and did not ensure consistent monitoring and documentation of their use for a resident identified as being at high risk for falls. The resident in question had significant cognitive impairment and required maximal assistance with mobility and self-care tasks. Medical records indicated that sensor alarm pads were ordered for both bed and wheelchair use, with informed consent obtained from the responsible party. However, documentation in the Medication Administration Record (MAR) showed missing entries for several shifts, indicating that monitoring of the sensor alarm pads was not consistently performed or recorded. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), confirmed that there was no existing policy or procedure for the use of bed and chair sensor alarm pads. Both staff members acknowledged that monitoring should occur every shift and be documented to ensure the devices were functioning and in place. The absence of a policy and inconsistent documentation of monitoring placed the resident at risk, as the intervention was not reliably implemented or tracked.