Failure to Complete Bed Alarm Assessment Prior to Use
Penalty
Summary
The facility failed to ensure that a bed alarm assessment was completed prior to implementing a bed alarm for a resident with significant cognitive impairment and a history of falls. The resident, who had diagnoses including Alzheimer's disease, major depressive disorder, repeated falls, vascular dementia, and anxiety, was admitted with severe cognitive impairment and a recent history of falls. Physician orders and the care plan indicated the use of a bed alarm to remind the resident not to get up unassisted, but there was no documentation of a bed alarm assessment or device decision assessment for this intervention. Observations on two separate occasions confirmed that the resident was in bed with the bed alarm in use. Interviews with an LPN and the Administrator verified the ongoing use of the bed alarm and acknowledged that the required assessment had not been completed. Review of facility policy defined physical restraints as any device that restricts freedom of movement and requires assessment prior to use, but this process was not followed for the resident in question.