Failure to Monitor and Maintain Safety Interventions for Resident
Penalty
Summary
The facility failed to properly monitor and maintain safety interventions for a resident with multiple diagnoses, including dementia, impaired cognition, and a history of falls. Physician orders were in place for an alarming Velcro seat belt and a pressure alarm to the resident's wheelchair for safety and positioning. However, there were no assessments completed to determine the necessity or appropriateness of these devices, and the care plan did not address the seat belt or provide a plan for monitoring or assessment of either device. Documentation in the progress notes did not justify the use of the devices or monitor their continued need, and the seat belt order was not included in the nursing assistant Kardex. Observations revealed that neither the seat belt nor the pressure alarm was in place as ordered, despite being signed off as checked and in place on the Treatment Administration Record. Staff interviews confirmed the devices had been removed at some point without documentation of the removal or rationale, and staff could not specify when or why the devices were discontinued. Facility policy required monitoring and documentation of the efficacy of such interventions, but this was not followed, resulting in a lack of oversight and failure to ensure the resident's safety interventions were properly managed.
Plan Of Correction
Resident #25 was immediately assessed and found to have no adverse effects. All residents with safety interventions have the ability to be effected. Resident #25 seatbelt immediately DCed by DON. Education provided to all staff by DON on 5/22/25 regarding alarm/ restrictive device policy. All residents with orders for restrictive devices/alarms were audited by IDT team on 5/22/25 to ensure they are appropriate, in place, and have required documentation. Don/Designee to audit 2 residents weekly ensuring that proper documentation is in place for their safety interventions for 4 weeks to ensure compliance. Results to be reviewed in QAPI.