Failure to Care Plan and Properly Implement Tab Alarm Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure an area was free from accident hazards and that adequate supervision and safety devices were properly care planned and implemented 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. The physician ordered a tab alarm for the resident, and a fall risk assessment identified the resident as being at risk for falls. On the day of the incident, 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 that should sound when the resident moves or when the magnet is displaced, and that the same alarm was used in both bed and wheelchair. The CNA explained that when a family member asked about providing personal hygiene care, the CNA left the room to obtain supplies, leaving the resident in a wheelchair and the tab alarm on the bed with the magnet still connected to the alarm unit. Because the alarm was not attached to the resident and the magnet remained in place, no alarm sounded when the resident moved. Interdisciplinary team notes documented that the resident slid off the wheelchair onto the floor while the CNA was out of the room and the family member had walked out of the room with the tab alarm off. When the CNA returned, the resident was found lying on the floor and reported left elbow pain; the resident was later transferred to a higher level of care and diagnosed with an acute fracture. Review of the comprehensive care plan showed there was no specific care plan for the use of the tab alarm, despite the physician’s order. Facility staff acknowledged that there was no care plan for the alarm and that this resulted in no defined interventions for nurses to follow, and that the tab alarm was not implemented correctly at the time of the fall, contrary to the facility’s policies on resident alarms and comprehensive care plans.
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