Resident 1 was found sitting on her bedroom floor at 6:45 a.m. on April 23 with severe pain in her right shoulder and arm, rating it 10 out of 10. X-rays revealed an acute displaced fracture of her upper arm bone near the shoulder.
The facility's interdisciplinary team met with her family member two days later and agreed she needed a bed alarm. Her care plan was updated on April 25 to require the device while she was in bed.
But when inspectors arrived April 29, the alarm wasn't working.
During their visit at 8:15 a.m., inspectors watched the resident lift her buttocks and waist from the bed. No alarm sounded. The resident told them she had a bed alarm "but it was off today and was not working." She said she didn't remember where she fell but knew it was on her right side because of her broken shoulder.
Licensed Vocational Nurse 1 told inspectors at 8:35 a.m. that the resident "did not have a bed alarm." A certified nursing assistant said the same thing 11 minutes later.
The Director of Staff Development found the problem at 9 a.m. A blue alarm box hung on the right side of the bed with no light on. The wire from the sensor pad wasn't connected to the alarm machine. When the director plugged it in, a green light turned on and the device beeped.
The licensed vocational nurse admitted he should have checked that the alarm was working. "The importance of bed alarm was for Resident 1's safety, to prevent another fall," he told inspectors.
The Director of Staff Development said certified nursing assistants, licensed vocational nurses and registered nurses were all responsible for ensuring bed alarms function properly.
The Director of Nursing explained that bed alarms alert staff when residents try to get up unsupervised. "If bed alarm was not turned on and not working the risk of Resident 1 falling again can happen," she said. "The nurse should check the bed alarm if its working."
The resident had multiple conditions that increased her fall risk. She had been admitted April 22 with diagnoses including unconfirmed fractures of two vertebrae in her middle back, a history of falls, and dementia.
Her fall risk assessment showed she had hypertension, vertigo, stroke history, arthritis, osteoporosis and fractures. Despite these conditions, the assessment scored her as low risk for falls with a total score of eight out of 10.
Both the Director of Staff Development and Director of Nursing said the assessment was wrong. The Director of Nursing said the resident should have been classified as high risk because she had a history of falls, high blood pressure, osteoporosis and fractures.
"Because of incorrect Fall Risk Assessment, intervention was inaccurate, and the facility will not be able to implement necessary intervention specific to Resident 1," the Director of Nursing told inspectors. "Safety measure will not be implemented that can jeopardize resident safety."
She said the registered nurse should have thoroughly assessed the resident and reviewed her medical history and diagnoses before completing the fall risk assessment.
The facility's own policy requires staff to use devices like bed alarms to remind residents to call for assistance and prevent them from getting up unassisted. The policy states that devices should protect residents from sustaining major injuries.
The facility's fall prevention protocol requires nurses to assess residents' risk factors including recent injuries, fractures, musculoskeletal function, pain, neurological status and all active diagnoses. It specifically lists osteoporosis as increasing fracture risk from falls.
The resident was admitted with the mental capacity to understand and make decisions, according to her medical examination. But her dementia diagnosis and history of falls made the bed alarm a critical safety measure.
The inspection found the facility failed to ensure the resident received the fall prevention intervention her care team had determined was necessary after her shoulder fracture.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Astoria Healthcare Center from 2025-04-29 including all violations, facility responses, and corrective action plans.