Non-Functional Wheelchair Pad Alarm for High Fall Risk Resident
Penalty
Summary
The facility failed to ensure that a wheelchair pad alarm was functional for a resident identified as being at high risk for falls. The resident, who had diagnoses including unspecified dementia and Alzheimer's disease, was assessed as having severely impaired cognition, unsteady gait, poor safety awareness, and a history of attempting to self-transfer from bed and wheelchair. The resident's care plan and facility policy required the use of a safety device pad alarm when the resident was in a wheelchair or bed to alert staff if the resident attempted to get up unassisted. During an observation, it was found that the resident's wheelchair pad alarm was disconnected because the cable was broken. Both the Director of Staff and Development and the Director of Nursing confirmed that the alarm was not functioning and acknowledged that it was necessary for the resident's safety. The facility's policy specified that alarms should be applied and maintained according to manufacturer instructions to ensure functionality, but this was not followed, resulting in the deficiency.