Failure to Maintain Comfortable Sound Levels Due to Inappropriate Alarm Use
Penalty
Summary
The facility failed to maintain comfortable sound levels for a resident who was reviewed for accidents. The resident, who had diagnoses including rheumatoid arthritis, diabetes mellitus, and a stage four sacral pressure ulcer, was cognitively intact but required total or substantial assistance with most activities of daily living. She had a care plan and physician's orders for bed and chair alarms due to her risk of falls, including a history of climbing out of bed and unplugging her alarm. During observation and interview, the resident reported that the bed alarm beeped frequently and was very loud, which she disliked. Interviews with the DON revealed that the facility was not routinely monitoring the efficacy of alarm use for residents, including this resident, and lacked documentation or verification that alarms were being used to assess residents' patterns and routines. The facility's own policies required regular review of alarm effectiveness, documentation of findings, and minimizing institutional characteristics such as bed and chair alarms to maintain a homelike environment with comfortable sound levels. These requirements were not being met, resulting in the deficiency.