Failure to Obtain Order and Monitor Use of Position Changing Alarm Device
Penalty
Summary
The facility failed to ensure that a position changing alarm device, used as a physical restraint for fall prevention, was properly ordered and monitored for a resident identified as being at risk for falls. Observations showed the resident had a position changing alarm in both her bed and wheelchair, but there was no physician or nurse practitioner order for the device, nor was there documentation of monitoring its use or effectiveness. Interviews with staff, including the CNA, DON, and Unit Manager, confirmed that the alarm was implemented after the resident experienced an unwitnessed fall, but none were aware that an order or ongoing documentation was required. The facility's own policy stated that an order and monitoring were necessary for such devices. Record review revealed that the resident had diagnoses including traumatic subarachnoid hemorrhage, secondary malignant neoplasm of bone, and vascular dementia, with a moderately impaired mental status. The care plan identified a risk for falls and included monitoring changes in gait and positioning, but did not specifically address the use or monitoring of the alarm device. Nursing notes and orders from the relevant period did not mention the alarm or its monitoring, despite a note indicating the resident had turned off the alarm multiple times. The lack of an order and monitoring for the restraint device constituted the deficiency.