Failure to Ensure Functioning Bed and Wheelchair Alarms
Penalty
Summary
The facility failed to ensure that essential equipment, specifically bed and wheelchair alarms, were functioning properly for a resident with diagnoses including Parkinson's disease, encephalopathy, and abnormal gait and mobility. The resident required moderate assistance with mobility and had orders for sensor pads in both bed and wheelchair to alert staff when attempting to get up unassisted. During observation, the bed alarm functioned as expected, but the wheelchair alarm did not sound when the resident was assisted to stand. The Assistant Director of Nursing attempted to fix the pad and switch alarms, and only after switching to a different alarm did the device function correctly. Interviews with facility leadership revealed there was no monitoring system in place to check the functionality of bed and wheelchair alarms, and no policy or procedure regarding the use of tab alarms. Review of facility policies indicated a general requirement to maintain equipment in good working order, but there was no specific guidance or monitoring process for the alarms in question. This lack of oversight and procedure led to the failure to ensure the resident's safety equipment was consistently operational.