Failure to Implement Care Plan Intervention for Chair Alarm
Penalty
Summary
The facility failed to implement a care plan intervention for a resident by not ensuring the proper use of a chair alarm as specified in the individualized care plan. The care plan, dated September 5, 2025, required the use of an electronic chair alarm to alert staff of unassisted rising, with instructions to ensure the device was in place every shift. On October 7, 2025, the resident was found on the floor in their room, with the fall investigation revealing that the chair alarm was not connected properly at the time of the incident. The resident's fall prevention measures included bed and chair alarms, hourly checks due to poor safety awareness and fall risk, nonskid socks while in bed, and staff supervision in the bathroom. The Director of Nursing confirmed that the chair alarm was not connected as required by the care plan when the fall occurred. The deficiency was identified through a review of clinical records, the facility's fall investigation, and staff interviews, which established that the intervention to provide a properly functioning chair alarm was not implemented as directed in the resident's care plan.