Failure to Ensure Functioning Fall Prevention Alarms and Adequate Supervision
Penalty
Summary
The facility failed to ensure that fall prevention measures were in place and did not implement a system to verify that bed and chair alarms were functioning for a resident identified as high risk for falls. The resident had multiple diagnoses, including schizophrenia, anxiety disorder, dementia, movement disorder, bipolar disorder, and unsteadiness on feet, and was assessed as having moderate cognitive impairment. The resident's care plan identified impulsive behavior, cognitive impairment, and gait/balance problems as risk factors for falls. Despite these risks, there were no physician's orders for bed or chair alarms, no routine documentation of alarm checks, and no care plan documentation indicating the use of alarms for this resident. On the date of the incident, the resident experienced a fall resulting in a forehead laceration, and it was noted that the bed alarm did not activate as expected. Staff interviews revealed that there were no established routines or documentation practices for checking the functionality of bed alarms. Maintenance staff confirmed that routine checks were not performed, and nursing staff indicated that they assumed alarms were working unless a low battery indicator was present. The facility's policies required verification of alarm functionality when alarms were used, but this was not consistently implemented or documented.