Failure to Ensure Bed Alarm Monitoring for Fall-Risk Resident
Penalty
Summary
The facility failed to ensure that an intervention was in place for staff to monitor the placement and functionality of a resident's bed alarm. A resident with diagnoses including epilepsy and convulsions, and identified as being at risk for falls due to seizures, was observed with a bed alarm in place. The care plan indicated the need for a bed alarm for safety, but after an unwitnessed fall where the resident was found on the floor with the bed alarm cord ripped from the alarm, the care plan was updated to use a cordless alarm. However, prior to a specific date, the clinical record did not contain documentation of an order for staff to check the placement and function of the bed alarm every shift. Interviews with facility leadership confirmed there was no policy on bed alarms and that staff were expected to check the alarm every shift.