Failure to Assess and Document Use of Position Change Alarms as Potential Restraints
Penalty
Summary
The facility failed to ensure that position change alarms were properly assessed as potential restraints and that appropriate consents and physician orders were obtained prior to their use. Specifically, for two residents with Alzheimer's disease and muscle weakness, position change alarms were implemented as fall prevention devices without documentation that less restrictive interventions had been attempted first. There was also no assessment in the residents' records regarding the use of these alarms as potential restraints. Observations confirmed that both residents were using tab alarms attached to their wheelchairs and clipped to their shirts. Interviews with the DON revealed that while fall risk assessments were completed, no specific assessment was conducted before placing the alarms, and consents were not obtained from the residents' representatives. The facility's policy required monitoring and documentation of interventions, but these steps were not followed in these cases.