Failure to Obtain Orders, Assessments, and Consents for Chair and Bed Alarms
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality by not obtaining physician's orders, resident representative authorization, or completing assessments for the use of chair and bed alarms for three residents. Facility policy requires an assessment of the need for restraint use, obtaining a physician's order, and developing or reviewing a care plan for the type of restraint, reason for use, and methods to reduce or eliminate restraint. Despite these requirements, there was no documentation of assessments, orders, or consents for the use of chair or bed alarms for the residents in question. For one resident with moderately impaired cognition, a history of falls, and diagnoses including Parkinson's Disease and seizure disorder, a chair alarm was used daily without a physician's order, assessment, or consent. Observations confirmed the presence of the alarm, and staff interviews indicated the alarm was used due to the resident's tendency to attempt to get up unassisted. The care plan referenced the use of the alarm at the family's request, but there was no supporting documentation in the medical record for the required assessment or authorization. Another resident with severely impaired cognition, dependent for all mobility, and a history of falls, was observed with a chair alarm in use. The care plan and staff interviews confirmed the use of alarms, but again, there were no physician's orders, assessments, or consents documented. A third resident, also with severely impaired cognition and a history of falls, was observed with both chair and bed alarms in use, but lacked the necessary documentation and authorization. The DON and Administrator confirmed that assessments, orders, and consents were not completed for residents with alarms, contrary to facility policy and expectations.