Failure to Ensure Proper Functioning of Bed Alarm Results in Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a bed alarm intervention worked properly for a resident with a history of falls and moderate cognitive impairment. The resident required substantial to maximal assistance with mobility and had a care plan that included the use of bed and chair alarms to alert staff when assistance was needed. Despite these interventions, the resident experienced a fall in the bathroom during the night, and it was discovered that the bed alarm did not sound as intended. Clinical documentation and staff interviews revealed that the bed alarm was in place but failed to activate when the resident left the bed. Staff members, including a CNA and RN, confirmed that the alarm did not sound on their phones or audibly, and the issue was only discovered after the resident was found on the bathroom floor. The alarm was later tested and found to function intermittently, with staff noting that wiggling the cord could restore its function. The resident's husband also confirmed that bed alarms were present but did not prevent the fall. The facility's policy required that fall prevention interventions, such as bed alarms, be in working order and checked regularly. However, the failure to ensure the alarm's functionality directly contributed to the resident's unwitnessed fall. The resident sustained a compression fracture of the lumbar spine, as indicated by radiology reports, although the acuity of the fracture was indeterminate. Staff interviews further confirmed reliance on the alarm system for resident safety, and the deficiency was attributed to the alarm's malfunction at the time of the incident.