Failure to Obtain Orders and Informed Consent for Tab Alarms
Penalty
Summary
The facility failed to ensure that tab alarm orders and informed consents were obtained for two residents. For one resident, a tab alarm was observed attached to the resident's wheelchair and T-shirt, but there was no physician order for the alarm, and the informed consent form was unsigned by the resident's representative. The resident's care plan referenced the use of a bed alarm and tab alarm, but the Minimum Data Set (MDS) did not indicate the use of a chair alarm. The Assistant Director of Nursing (ADON) confirmed the absence of both the required order and signed consent. For another resident, a tab alarm was also observed in use while the resident was in a wheelchair. The MDS indicated daily use of a chair alarm, and the medical orders included a tab alarm while in the chair. However, there was no informed consent for the tab alarm in the medical record, and no care plan had been initiated for its use. The ADON and a Licensed Vocational Nurse (LVN) confirmed the lack of consent and care plan documentation. Additionally, the ADON stated that there was no alarm policy or process in place at the facility.