Failure to Maintain Functioning Pad Alarm Resulting in Unassisted Fall
Penalty
Summary
The deficiency involves the facility’s failure to maintain a functioning chair/bed pad alarm for a resident identified as being at risk for falls. The resident was admitted with multiple significant diagnoses, including chronic kidney disease, shortness of breath, anxiety disorder, torsades de pointes, sepsis, atrial fibrillation, heart failure, acute respiratory failure with hypoxia, restlessness and agitation, muscle weakness, unsteadiness on feet, cerebral infarction, and osteoarthritis. The resident’s MDS documented a severely impaired BIMS score of 4, and the care plan identified the resident as at risk for falls due to a history of falls on admission and weakness, with interventions including a chair pad alarm and bed pad alarm. The facility’s fall prevention policy required confirmation that bed/chair alarms are functioning when ordered, and staff reported that bed and chair alarms are to be checked for working status every shift. Despite these identified risks and interventions, an incident note documented that the resident was found ambulating unassisted to the bathroom, with the bed pad alarm in place but not sounding. During this unassisted ambulation, the resident became unsteady, turned, and hit the back of the head on a closed bathroom door, then slid to the floor and landed on the back. An LPN immediately assessed the resident, noting range of motion within normal limits, usual confusion, and a raised area developing on the posterior head. The administrator later confirmed that when the resident fell, the pad alarm was not sounding and that it should have been, indicating that the alarm was not functioning as required at the time of the fall.
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