Failure to Ensure Proper Functioning Bed Pad Alarm for Resident at Fall Risk
Penalty
Summary
A deficiency occurred when a resident with a history of falls, right femur fracture, hemiplegia, morbid obesity, dementia, and moderately impaired cognition was not provided with a properly functioning bed pad alarm as ordered by the physician. The resident required significant assistance with daily activities and was dependent on staff for toileting, showering, and dressing. The physician had ordered a bed pad alarm to decrease the potential for injury, and facility policy required daily checks of such alarms for proper functioning. During an observation, a CNA attempted to demonstrate the bed pad alarm but no alert was heard, and both the CNA and DON confirmed the alarm was not working. The Central Supply Manager stated that position change alarms are typically checked daily, but on this day, the resident's alarm had not been checked. The DON acknowledged that the alarm should be operational at all times and confirmed it was not working at the time of inspection, which was inconsistent with facility policy and physician orders.