Staff B, a registered nurse at Southeast Iowa Regional Medical - Klein Center, found the resident on the bathroom floor. The resident couldn't remember why she was in the bathroom.
"Resident #1's bed alarm did not sound on her phone," Staff B told inspectors on October 30. When she checked the alarm system, "if you wiggled the cord, the bed alarm came back on."
The facility uses bed and chair alarms for residents who cannot communicate or know to use their call lights, according to the Director of Nursing. The alarms connect to staff phones or can be set to audible alerts to notify workers when residents are getting up.
But this system failed when the resident needed it most.
Staff B told the day shift to replace the bed alarm because she didn't have access to new devices. Staff C, the RN Unit Manager, later confirmed the bed alarm didn't sound during the incident. The staff "trouble shot the alarm and changed the batteries, even though the batteries were not completely dead and the bed alarm worked again."
After the fall, staff switched the resident's alarm from phone notification to audible alert.
The Director of Nursing confirmed to inspectors that the bed alarm did not function when the resident got up and fell. During questioning about alarm expectations, she said the facility would now require nurses to check bed alarms every shift "just like a wander guard."
A physician assistant who evaluated the resident after the fall noted potential for an acute fracture. The PA said he could only document what the radiologist reported.
Federal inspectors reviewed the facility's fall procedure from March 2024, which requires staff to note environmental factors that may have contributed to falls and review care plans for current fall prevention measures. The policy states that new or edited interventions must be tried to prevent recurring falls.
The inspection also referenced instructions for sensor pad monitors that require staff to test the devices by placing users on the pad surface to ensure proper function. When placed correctly, the monitor should sound an alarm if the user removes weight from the pad.
This equipment failure highlights a gap between policy and practice. The facility had procedures requiring environmental assessments after falls and regular equipment checks, but the faulty alarm went undetected until after the resident was injured.
The loose cord that Staff B discovered by wiggling suggests the alarm may have been malfunctioning for an unknown period before the fall. Neither the daily operations nor the equipment protocols caught this mechanical failure that left a vulnerable resident without the safety monitoring her care plan required.
Staff C's troubleshooting after the incident revealed that even batteries that weren't completely dead could cause alarm failures. This discovery came only after a resident was found injured on a bathroom floor, raising questions about how many other alarm malfunctions might go unnoticed until someone gets hurt.
The facility's response was to switch this resident's alarm to audible and implement daily equipment checks. But for this resident, those improvements came too late. She had already experienced the fall that the bed alarm was specifically installed to prevent.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Southeast Iowa Regional Medical - Klein Center from 2025-10-30 including all violations, facility responses, and corrective action plans.
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