F0604

D

Failure to Assess and Justify Ongoing Use of Bed and Chair Alarms as Physical Restraints

Tipton, Indiana Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

Surveyors found that a resident with diagnoses including major depressive disorder, muscle weakness, and dementia was subjected to ongoing use of a bed alarm and a pull (chair) alarm without proper assessment, documentation, or physician orders that met regulatory and facility policy requirements. The resident was observed with a pull alarm attached to her and her wheelchair, and a device connected to her bed. Physician orders dated 9/24/25 directed use of a pull alarm when in the wheelchair and a bed alarm when in bed every shift, but these orders lacked a related diagnosis or indication for use and had indefinite end dates. The alarms were initiated after a fall on 9/24/25, and the resident had no documented falls for more than seven months afterward, yet the alarms continued to be used.

The facility’s documentation did not include an initial physical restraint assessment, did not show that least restrictive interventions were attempted and failed before initiating the alarms, and did not contain quarterly physical restraint/device reassessments as required by facility policy. An IDT note from 9/25/25 documented that the team met after the fall, noted placement of a pull alarm as an immediate intervention, and recommended continuing the alarm with routine evaluations, but did not discuss which less restrictive alternatives had been tried first. Fall assessments later provided by the facility did not mention the alarm devices. During interviews, the DON acknowledged there was little documentation about the devices, could not produce reassessments that addressed the alarms, and later stated it did not appear the resident needed the bed and chair alarms, while also asserting that the facility followed all federal and state regulations.