F0689

D

Failure to Ensure Functioning Motion Sensor Alarms and Staff Response for High Fall-Risk Residents

Pomona, California Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that motion sensor alarms used as fall-prevention interventions were functioning and appropriately monitored for two residents identified as high fall risk. Resident 2 was admitted with dementia, gait and mobility abnormalities, and was assessed on the MDS as dependent in ADLs with short- and long-term memory problems. A Morse Fall Scale dated 1/8/2026 showed Resident 2 was at high risk for falls, and the care plan, revised the same day, included a motion sensor alarm in the room as an intervention due to impaired balance, impaired mobility, and attempts to get out of bed unassisted. Resident 3 was admitted with a history of falling and muscle weakness, had a care plan indicating risk for recurrent falls related to impaired balance and mobility, and had an assisted fall on 12/23/2025 when attempting to walk without calling for staff. Resident 3’s MDS showed intact cognition with a need for maximal assistance, and a Morse Fall Scale dated 12/30/2025 also identified high fall risk; the care plan likewise included a motion sensor alarm.

Surveyor observations and staff interviews showed that the wireless sensor alarm system was not being used as intended and was not reliably functional. CNA 2 reported having two alarms for these residents and produced two white alarm devices from a pocket. CNA 1 explained that the facility practice was for CNAs to carry a white device paired with the room sensor and to respond visually to the resident when the device sounded after motion was detected. The DON stated that CNAs needed to carry the sensor alarms at all times and that response to an activated alarm should be immediate, with CNAs expected to leave the alarm with nursing staff if they were too busy to respond. Despite these stated practices, subsequent testing of the alarms and staff response revealed failures.

During observations with LVN 2, the motion sensors in both residents’ rooms were positioned on tables facing the residents in bed. When LVN 2 moved in front of Resident 2’s sensor to activate it and then waited in and outside the room, CNA 2 did not respond, and there was no audible alarm sound heard between 2:37 PM and 2:41 PM; CNA 2 also did not communicate being busy. A similar test in Resident 3’s room showed no audible alarm and no response from CNA 2. CNA 2 was later observed in the staff lounge. When CNA 2 then moved in front of both residents’ sensors, the alarm device in CNA 2’s pocket did not sound until a button was pressed, after which an audible alarm was heard; CNA 2 stated the alarm might have turned off while in the pocket. The facility’s product description for the alarms indicated they are wireless bed alarms intended to alert staff when a patient gets up so staff can assist to prevent falls, and the facility’s fall prevention policy described a program to identify fall risk and implement interventions, but the alarms for these two high-risk residents were not functioning or being monitored as required at the time of surveyor observation.