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F0604
D

Failure to Obtain Informed Consent for Bed Alarm Use

Sylmar, California Survey Completed on 10-14-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to obtain informed consent from a resident's responsible party (RP) prior to the use of a bed alarm, which is considered a safety device that alerts staff when a resident attempts to get out of bed. The resident in question was admitted with diagnoses including muscle weakness, a history of falls, and dementia, and was assessed as lacking the capacity to make medical decisions. Following a fall, the medical doctor ordered the use of a bed alarm, and the device was implemented immediately. However, documentation and interviews revealed that informed consent from the resident's RP was not obtained until nearly two weeks after the bed alarm was put in place. The care plan and medical records indicated that the resident was at high risk for falls and required substantial assistance with daily activities. Despite facility policy requiring written physician orders and consent from the resident or their representative before using restraints or similar safety devices, the bed alarm was used without prior consent. The Director of Nursing confirmed that consent should have been obtained at the time the bed alarm was ordered and acknowledged the lapse in following the facility's policy and procedures.

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