Failure to Maintain Functional Bed Alarm for High Fall Risk Resident
Penalty
Summary
The facility failed to maintain a bed alarm in proper working condition for a resident identified as high risk for falls. The resident, who had diagnoses including metabolic encephalopathy, Parkinson's disease, and muscle weakness, was assessed as having severely impaired cognition and required substantial to maximal assistance with activities of daily living. The resident's care plan required the use of a sensor pad alarm when in bed or wheelchair due to a tendency to attempt to get up unassisted. During observation, the bed alarm was found hanging on the side of the bed without batteries, rendering it nonfunctional. Both the LVN and DON confirmed that the bed alarm was not operational and emphasized its importance in alerting staff when the resident attempted to get up. Interviews revealed that there was no effective system in place to ensure bed alarms were consistently checked and maintained. The maintenance supervisor stated that bed alarms were only checked once a month and was unsure how to implement a monitoring system. The facility's policy indicated that the maintenance department was responsible for keeping equipment safe and operable at all times, but this was not followed in practice. As a result, the resident was left without a functioning bed alarm, placing them at risk for a preventable fall or accident.