F0656

D

Lack of Assessment-Based Care Planning for Bed and Chair Alarm Use

Danbury, Connecticut Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement a resident-specific, assessment-based care plan for the use of bed and chair alarms. Resident #1 had dementia with a BIMS score of 7/15 indicating severe cognitive impairment, atrial fibrillation, osteoporosis, multiple rib fractures, depression, a history of falls, and required partial to moderate assistance with ambulation and transfers. A quarterly MDS indicated no bed or chair alarms in use, while the resident’s care plan identified forgetfulness, poor safety awareness, and fall risk related to deconditioning, unsteady gait, and impaired mobility after a recent fall with rib fractures. The care plan directed use of bed and chair alarms per family request, along with other fall-prevention interventions, and a physician order later directed bed and chair alarms every shift.

On observation, the resident was found sitting on the bed with an active bed alarm and a chair alarm present on the recliner, and the DON confirmed that bed and chair alarms were used at all times for this high fall-risk resident, who did not use the call bell and attempted to get out of bed alone. However, record review did not identify any comprehensive assessment or fall risk documentation addressing the clinical need, effectiveness, or individualized parameters for alarm use. There was no documentation explaining the rationale for alarms, any alternatives or less restrictive interventions trialed, or any assessment of whether the alarms constituted a restraint. The DON acknowledged that an assessment for alarm use had not been completed and could not provide documentation that less restrictive measures were attempted, despite the facility’s own Chair/Bed Alarm Policy describing alarms as alternatives to restraints and tools to alert staff when residents attempt to stand alone.