Failure to Implement Care Plan Chair Alarm Intervention for Fall Risk Resident
Penalty
Summary
The facility failed to implement a care plan intervention for a resident identified as being at risk for falls. The resident, who had severe cognitive impairment as indicated by a BIMS score of 2 out of 15, required substantial to maximal assistance for transfers and ambulation. The care plan, created in February and updated in March, included the use of a chair alarm to alert staff when the resident attempted to self-transfer. However, on the date of the incident, staff observed the resident stand up impulsively from a wheelchair and immediately fall. Multiple staff members present during the fall did not recall a chair alarm being in place at the time. Interviews with staff, including the staffing coordinator, activities director, social services designee, and DON, confirmed that the chair alarm, as specified in the care plan, was not in use during the fall. The facility's policy required the use of alarming devices to alert staff of position changes for residents with diminished cognition. Despite this policy and the care plan intervention, the chair alarm was not implemented at the time of the incident, resulting in a failure to follow the established care plan for fall prevention.