Failure to Ensure Functioning Bed Alarms and Adequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents at high risk for falls. One resident, with a history of falls, dementia, muscle weakness, and a recent hip fracture, was repeatedly attempting to get out of bed unassisted. Despite a physician's order and care plan interventions requiring a functioning bed pad alarm and staff supervision, the alarm was not plugged in or functioning at the time the resident attempted to get out of bed. The family-provided companion notified staff multiple times about the resident's attempts to get up, but the assigned LVN did not check the alarm, did not notify the RN, and did not provide additional interventions. The resident subsequently had an unwitnessed fall, resulting in a severe right arm fracture, blunt head trauma, and required hospitalization and surgery. After the fall, the LVN and CNA moved the resident back to bed without waiting for an RN assessment, contrary to facility policy and job descriptions, which require an RN to assess a resident before moving them after a fall. The RN and DON confirmed that this action was not within the LVN's scope of practice and could have contributed to further injury. Interviews with staff and review of facility policies confirmed that the responsibility for fall prevention and supervision remains with facility staff, regardless of the presence of a family-provided companion, who was not medically trained and was not responsible for direct care. A second resident, also at high risk for falls with a history of traumatic brain and bone injuries, was observed with a disconnected bed alarm despite a physician's order and care plan requiring its use. Multiple staff entered the room without checking or ensuring the alarm was functional. The DON acknowledged that the care plan was not implemented and that the pad alarm should be checked for functionality every time staff enter the room. Facility policies reviewed emphasized the need for individualized interventions, adequate supervision, and consistent use of assistive devices to prevent avoidable accidents, all of which were not followed in these cases.