Failure to Ensure Bed Alarm Activation Results in Resident Fall and Hip Fracture
Penalty
Summary
The facility failed to follow its policy and procedure regarding fall prevention interventions for a resident with a significant history of falls and cognitive impairment. The resident, who had diagnoses including Alzheimer's disease, unspecified dementia, major depressive disorder, recurrent mild muscle weakness, gait abnormalities, and a history of falls, was assessed as high risk for falls and had a care plan and physician order requiring a bed alarm to be activated whenever in bed. Despite these interventions, the bed alarm was not activated after the resident was changed in bed during a shift change. Interviews with the DON, ADON, licensed nurses, and a CNA revealed that staff could not recall if the bed alarm was turned back on after providing care, and documentation confirmed that the required alarm check was not completed for the evening shift. The facility's policy required alarms to be tested at the start of each shift and after resident care, but this was not consistently followed. The resident was found on the floor after calling for help, with no bed alarm or call light activated, and subsequently sustained a displaced right hip fracture. Record reviews, including care plans, physician orders, and progress notes, confirmed that the bed alarm was a required intervention for this resident due to poor safety awareness and a high fall risk. The failure to ensure the bed alarm was activated directly resulted in the resident being able to exit the bed unassisted, leading to a fall and serious injury. Staff interviews and documentation indicated lapses in following established protocols for alarm use and shift checks.