Failure to Maintain Functional Personal Alarm and Update Fall Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s personal alarm was functioning despite the resident being identified as at risk for falls. The resident had multiple medical conditions, including dementia, congestive heart failure, asthma, type 2 diabetes mellitus, dysthymic disorder, chronic kidney disease, arthropathy, benign prostatic hyperplasia, hypercholesterolemia, gastroesophageal reflux disease, obstructive sleep apnea, hyperparathyroidism, peripheral vascular disease, and hypertension. His care plan, dated 12/8/25, identified him as at risk for falls and required a sensor pad alarm to be in place when he was left unattended in bed, a chair, or a wheelchair. On 1/10/26, the resident experienced an unwitnessed fall in the bathroom; he was found on the floor in a supine position, unable to state what happened, and his alarm was noted to be not working. A CNA reported that the same alarm device was moved between the resident’s bed and chair and that he always had an alarm to alert staff when he tried to get up, as he liked to attempt getting up on his own and fell. An RN stated that on the date of the fall the alarm was not working, and that after she and a CNA replaced the batteries and manipulated the worn wire, the alarm started working. A second fall occurred on 1/23/26, when the resident was found on the floor with his back against his room door, leaning on his right elbow with his legs stretched out, and again his alarm did not sound. The resident stated he was going to the bathroom. A CNA who worked that shift reported that the nurse found the resident on the floor and that the alarm was not going off until the batteries were replaced. The CNA also stated that staff can tell when alarm batteries are going low because some alarms start beeping rapidly or make a humming noise, and that if staff keep resetting the alarm when this happens, the batteries will die and staff will not be aware. The Assistant Director of Nursing stated she was not aware that the resident had two falls in which it was documented that his alarm was not working, and confirmed that the alarm should be working because it is an intervention for falls. The resident’s care plan, dated 12/8/25, was not reviewed or revised to reflect the two actual falls in January 2026 or any changes made for fall prevention, despite the facility’s fall policy stating that residents are to be assessed and fall situations evaluated to identify risk factors and develop individualized interventions.
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