Failure to Ensure Proper Functioning of Fall Alarm
Penalty
Summary
A resident with diagnoses of dementia and Alzheimer's disease, who was severely cognitively impaired and required partial to moderate assistance for transfers, experienced a fall in their room. The resident was found lying on the floor by staff, and it was noted that although an alarm was present on the resident's recliner, it was not properly attached to the alarm box. Earlier in the day, hospice staff had provided a bath for the resident but did not reconnect the alarm correctly afterward. The facility's documentation indicated that the root cause of the incident was the alarm box malfunction, specifically that the alarm was not properly connected. The facility's policy requires that all accidents and incidents be investigated and reported, with the interdisciplinary team responsible for determining the root cause and implementing interventions. The failure to ensure the fall alarm was functioning as intended directly contributed to the resident's fall.