Failure to Monitor and Document Alarm Bracelet Checks for High-Risk Resident
Penalty
Summary
A resident with Alzheimer's disease, dementia, and major depressive disorder, who was assessed as high risk for wandering and elopement, was observed wearing an alarm bracelet intended to alert staff if the resident attempted to leave the facility unattended. The resident's care plan and physician's orders required that the alarm bracelet be checked for placement every shift and for functionality every day shift. However, a review of the Medication Administration Record (MAR) and treatment administration records (TAR) for the relevant month showed no documentation that these checks were being performed as ordered. Interviews with facility staff, including a licensed nurse and the Director of Staff Development, confirmed that there was no evidence the alarm bracelet was being monitored for placement or functionality as required. Both staff members acknowledged the importance of these checks to ensure the device was working properly. The facility's policy on safety and supervision also required that interventions to reduce accident risks, such as monitoring safety devices, be implemented correctly and consistently. The lack of documentation and monitoring represented a failure to follow professional standards of practice, facility policy, and physician orders.