Failure to Care Plan and Implement Ordered Tab Alarm Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan for the ordered use of a tab alarm for a resident at high risk for falls. The resident was originally admitted with metabolic encephalopathy, Parkinson’s disease, difficulty in walking, dementia, and Alzheimer’s disease. An MDS assessment showed the resident had severe cognitive impairment and was fully dependent on staff for toileting, dressing, and personal hygiene. A fall risk assessment identified the resident as being at risk for falls, and on 2/18/2026 the physician ordered the use of a tab alarm for this resident. However, there was no corresponding care plan created that outlined individualized interventions, measurable objectives, or timeframes for the use and monitoring of the tab alarm. On the date of the fall, a CNA reported that the resident was not alert, was fully dependent on staff, and required two-person assistance for transfers between bed and wheelchair. The CNA stated that the resident had a tab alarm intended to alert staff when the resident moved, and that the same alarm was used in both bed and wheelchair. The CNA described leaving the resident in a wheelchair with a family member present while the CNA left the room to obtain hygiene supplies. At that time, the tab alarm device was on the bed and not connected to the resident, and its magnet remained attached, so no alarm sounded. When the CNA returned, the resident was found on the floor, having slid from the wheelchair, and later reported left elbow pain. Interdisciplinary team notes documented that the resident slid off the wheelchair onto the floor after the CNA stepped out, and that the family member walked out of the room with the tab alarm off. Facility staff, including an LVN, acknowledged that they could not definitively identify who removed the alarm, and that there had been a failure in the system related to lack of staff education on tab alarm use, lack of family knowledge, and incorrect implementation of the alarm. Review of the comprehensive care plan confirmed there was no specific care plan for the tab alarm despite the physician’s order. Facility policies on resident alarms and comprehensive care plans required that alarms be used and monitored in accordance with the resident’s care plan and that each resident have a comprehensive care plan with measurable objectives and timeframes, but these requirements were not met for this resident.
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