Failure to Accurately Document and Assess Use of Bed/Chair Alarms for Fall Prevention
Penalty
Summary
The facility failed to ensure that a resident's comprehensive assessment accurately reflected the use of bed and chair alarms as interventions for falls. Despite documentation in progress notes and incident reports that staff were utilizing these alarms, the interventions were not included in the resident's care plan until after multiple falls had occurred. Additionally, the quarterly Minimum Data Set (MDS) assessment did not indicate the use of bed or chair alarms, even though progress notes during the assessment period documented their use. The Director of Nursing confirmed that the alarms should have been included in the MDS assessment based on the available documentation. The resident involved had a history of recurrent falls and sustained a left femur fracture requiring surgery following an unwitnessed fall at the facility. After re-admission post-surgery, new interventions were not developed, and the resident experienced two additional unwitnessed falls prior to discharge. The lack of accurate documentation and assessment of the use of bed and chair alarms as fall prevention interventions contributed to an incomplete and inaccurate assessment of the resident's status and care needs.