Failure to Ensure Proper Use and Monitoring of Bed Alarm for Fall Prevention
Penalty
Summary
The facility failed to properly implement and monitor a fall prevention intervention for a resident with Alzheimer's Disease, cognitive impairment, and mobility issues. The resident had a physician's order for a bed alarm to be checked for functioning every shift, and the care plan identified the resident as being at risk for falls due to incontinence, unawareness of safety needs, and sensory deficits. Despite these interventions, there were two documented incidents where the resident was found on the floor in their room. In the first incident, the bed alarm was present but the volume was turned down, so it did not sound when the resident attempted to get out of bed. In the second incident, the alarm was on the bed but not turned on, resulting in no alert when the resident left the bed. Further review of clinical documentation revealed multiple instances over a three-month period where staff failed to document that the bed alarm was in place and functioning as required by the physician's order. Staff statements confirmed that the alarm was either not sounding or not turned on during the incidents. These failures in ensuring the alarm was properly set and functioning, as well as lapses in required documentation, contributed to the resident's unassisted movement and subsequent falls.