F0689

D

Failure to Ensure Proper Use and Functioning of Motion Sensor Alarms for Residents at Risk for Falls

Georgetown, Indiana Survey Completed on 03-30-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that motion sensor alarms were properly functioning and appropriately ordered for residents at risk for falls. For one resident with dementia, moderate anxiety, and Parkinsonism, surveyors observed a motion sensor system consisting of a small box on the floor inside the room and an alarm box on the hallway handrail outside the door. Although a yellow light illuminated on the floor unit when motion was detected, the hallway alarm did not sound because the chime switch was not fully in the "on" position. The resident’s clinical record did not contain a physician’s order for the motion sensor alarm, nor documentation that the family had been notified or had agreed to the alarm placement, despite staff statements that motion sensors should only be used with a physician’s order and that they should be active when residents at risk for falls are alone in their rooms.

The facility also failed to ensure proper functioning of a motion sensor alarm for another resident with dementia, chronic pain, anxiety, and lack of coordination, who had an existing physician’s order for a motion sensor alarm every shift and an order for staff to check the alarm’s proper functioning every shift. The resident’s care plan documented that the resident was at risk for falls and was to have a motion sensor alarm as ordered for safety. During observation, surveyors noted the same alarm configuration, with a floor unit inside the room and an alarm box on the hallway handrail. The yellow light on the floor unit illuminated with motion, but the hallway alarm did not chime because the chime switch was not turned on, contrary to the physician’s order and care plan requirements for continuous use and regular function checks.