Failure to Provide Non-Alarm Interventions and Proper Alarm Reduction for Residents at Risk for Falls
Penalty
Summary
The facility failed to ensure that two residents at risk for falls were consistently provided with non-alarm interventions before and after the implementation of multiple alarms. Both residents were subjected to the use of several alarms simultaneously—one with five alarms and the other with four—without a documented plan to reduce alarm use or assess the necessity of concurrent alarms. The facility's own policies required that alarms be used on a short-term basis and that the interdisciplinary team review the potential for eliminating alarms while developing other strategies, but there was no evidence that these steps were followed. Additionally, alarm assessments were incomplete, with missing documentation and blank sections regarding alternative strategies and justification for alarm use. For one resident with mild cognitive impairment, legal blindness, abnormal gait, and anxiety disorder, alarms were used extensively, including a motion sensor, chair alarm, bed alarm, and a Tabs alarm. Observations revealed that the alarms were loud and disruptive, and the resident was unaware of the source of the noise. Despite the use of multiple alarms, the resident experienced several falls, some of which occurred when alarms failed to prevent self-transfers or were not in place. The care plan required the use of a gait belt for all transfers, but this was not consistently followed, and there was no documentation that nursing staff were notified when the resident refused the gait belt, as required by the care plan. For the second resident, who had dementia and a history of wandering and falls, multiple alarms were also used, including a bed alarm, chair alarm, motion sensor, and wander/elopement alarm. The care plan and assessments did not document the use of alternative interventions or a reduction plan for alarm use. There was also a lack of documentation in progress notes and social services notes regarding the discussion or justification of alarm use. Staff interviews confirmed that alarms were implemented based on the resident's history of falls, but there was no admission assessment or documentation of other options considered prior to alarm use.