Failure to Monitor and Document Bed Alarm Use as a Physical Restraint
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from physical restraint by not monitoring the use of a bed alarm device as ordered and care planned. The resident was initially admitted in 2022 and readmitted in 2026 with diagnoses including traumatic subdural hemorrhage, unspecified COPD, and muscle weakness. An MDS dated 10/31/2025 documented that the resident’s cognitive skills for daily decision-making were severely impaired and that the resident required staff supervision for hygiene, showering, dressing, transfers, and walking. A physician’s order dated 1/13/2026 authorized the use of a bed alarm device, and a device informed consent dated the same day showed that a family member gave permission for the alarm while the resident was in bed. The resident’s care plan, also dated 1/13/2026, identified fall risk and included an intervention to apply a bed alarm when the resident was in bed and to check its placement and function every shift. A subsequent physician order dated 1/14/2026 reiterated that the resident may use a bed alarm in bed and that staff should check placement and function every shift. The resident’s H&P dated 1/15/2026 documented that the resident did not have capacity to understand and make decisions. On 1/27/2026, during an observation and interview in the resident’s room, a bed alarm device was seen hanging on the left side of the bed, and an LVN stated the resident used the bed alarm in bed to alert staff when the resident got up. On 1/28/2026, during an interview and record review with the DON, the DON confirmed that the resident had been on a bed alarm since 1/13/2026 and described the bed alarm as the least form of physical restraint. The DON stated that residents on bed alarms should be monitored for placement and function of the alarm and that this monitoring should be documented on the MAR. Review of the MAR for January 2026 showed no documented monitoring from 1/16/2026 to 1/27/2026. The DON stated that monitoring and documentation were needed to ensure the bed alarm device was effective for the resident in preventing falls. The facility’s restraint policy, last reviewed on 1/14/2026, required that restraints be used only for safety and well-being after alternatives were tried, that the least restrictive alternative be used for the least amount of time, that ongoing re-evaluation be documented, and that a resident placed in a restraint be observed at least every 30 minutes with an account of the resident’s condition recorded in the medical record, along with detailed documentation of the restraint episode and monitoring. These policy requirements were not met for this resident’s bed alarm use.
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