Failure to Implement Bed Alarm as Fall Prevention Intervention
Penalty
Summary
A deficiency occurred when the facility failed to implement a fall prevention intervention as outlined in a resident's care plan. During observation, a resident was found lying in bed with a bed alarm sensor pad in place, but the sensor's cord was not plugged into the alarm module. The alarm module itself was located across the room, approximately eight feet away from the bed, making it nonfunctional. The resident did not respond verbally to greetings or questions at the time of observation. A registered nurse confirmed that the alarm was not connected as required by the care plan, which specified the use of a bed alarm for safety and increased supervision in the resident's room. The care plan interventions had been initiated prior to the observation, but the required equipment was not properly set up, resulting in the failure to provide the intended fall prevention measures.