Failure to Evaluate Use of Bed and Chair Alarms as Physical Restraints
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including unspecified dementia, Parkinson's disease with dyskinesia, anxiety disorder, and depression, was found to have a bed alarm in place. The resident's clinical record included physician orders for the use of a bed alarm and care plan documentation for both bed and chair alarms. The Minimum Data Set assessment indicated daily use of these alarms, and the resident required partial to moderate assistance with bed mobility and transfers. Despite the use of these alarms, there was no documented evidence in the clinical records that the resident had been evaluated for the use of a chair or bed alarm. This lack of evaluation was confirmed during an interview with the unit manager, a registered nurse. The failure to assess the need for these devices resulted in the facility not ensuring the resident was free from physical restraints, as required.