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Facts About F-Tag 323
Creating a Culture of Fall Alarm Safety
As Part Of A Total Fall Management Program

Never Events
by Rein Tideiksaar, PhD


Fall alarms are often employed by nursing facilities as a strategy to help prevent falls. To assist staff in their prevention efforts, it’s important that alarms are functioning and used properly. The intent of this guidance is to help facilities develop a ‘culture of fall alarm safety’ and avoid survey deficiencies.

Facts About F-Tag 323: Fall Alarms

F Tag 323 requires nursing facilities to ensure that each resident receives adequate assistive devices to prevent accidents (falls). "Assistive Devices" refers to any item (such as grab bars, cane/walker, wheelchair, transfer lift, etc.) that is used by, or in the care of a resident to promote, supplement, or enhance the resident’s function and/or safety. Fall alarms classify as assistive devices.

CMS (Centers for Medicare and Medicaid Services) places a heavy focus on facilities employing a systems approach, or systematic approach, to comply with the intent of the federal regulations.

With respect to fall alarms, core steps of the systems approach applied to F Tag 323 requirements are as follows:

Implementation of interventions, including adequate supervision and assistive devices, to reduce individual risks related to hazards in the environment. This relates to implementing the plan of care, which includes:

  • Communicating the use of an intervention (fall alarm) to all relevant staff.
  • Implementing the intervention (fall alarm).
  • Assigning responsibility for ensuring that the intervention (fall alarm) is 'in place'.
  • Documenting that the fall alarm is ‘in place’ and functioning properly.
  • Providing staff training as needed to ensure that alarms are functioning and used properly

Monitoring for effectiveness and modification of interventions when necessary. This means periodically reviewing the plan of care and monitor its effectiveness, which includes:

  • Ensuring that fall alarms are implemented correctly and consistently.
  • Evaluating the effectiveness of alarms.

Fall Alarm Deficiencies

Any failure to comply with regulations can result in fall alarm deficiencies, which may include:

  • SUA-1 Universal Alarm Alarm listed in care plan as a fall preventive strategy but not in place (i.e., not being used by a resident or residents at the time of survey to monitor risk).
  • Alarm not functioning properly; alarm broken (not sounding), alarm cord disconnected from the alarm box or alarm settings not set up properly. It is always best practice to utilize tamper-proof fall alarms that residents cannot disconnect the cord from the alarm.
  • Resident disables alarm (i.e., it’s a facility’s duty to ensure that fall alarms are operating properly when residents have the ability to disable the system). It is always best practice to utilize tamper-proof fall alarms that residents cannot disable.
  • Not knowing which residents are receiving alarms; failing to maintain a master list of residents who wear alarms.
  • Not having a location or section in residents’ health records to document use of fall alarms; failing to document alarms in the health records.
  • Staff not responding to sounding fall alarms in a timely manner.
  • Alarm is used to substitute for direct supervision of residents who are at fall risk.
  • Alarm is a physical restraint (i.e. an alarm may be considered a restraint if the resident reports or appears to be afraid to move because the alarm will go off).
  • Effectiveness of alarms in reducing fall risk not monitored.
  • Alarms were not applied or used in accordance with the residents’ care plan.


To reduce the likelihood of alarm deficiencies, there are a number of steps that facilities can take, which include:

  • Maintain a master list of residents who use alarms so that facility staff members do not have to consult individual charts for that information. As an alternative, facilities can choose to maintain a floor or unit master list.
  • Assign a nursing staff member to supervise and check on residents with fall alarms (i.e., to ensure that alarms are properly functioning and in place). Make sure that alarms are used in accordance with the resident’s care plan.
  • SUA-120 Tamper-resitent alarmMaintain adequate supervision of residents at fall risk; alarms may be used to enhance direct supervision but should never be used to substitute for supervision.
  • Conduct alarm assessments on a quarterly basis to evaluate the effectiveness of alarms; document the continued appropriateness of alarm use. Reassess alarms regularly with significant resident change and determine what type of alarm is most appropriate.
  • Assess staff proficiency with fall alarms on a regular basis; make sure nurses understand the purpose of fall alarms and how to operate alarms. Also, nurses should react to the needs of the resident (i.e., toileting, thirst/ hunger, activity, pain, etc.), not just the alarm sound.
  • Maintain policies/protocols governing use of fall alarms; make sure that current policy/protocol and fall alarm practice are in sync. Policies should also cover alarm safety checks and maintenance.
  • Develop a policy/protocol for residents who disable their alarms, which may include modifying or replacing alarms as needed. It is always best practice to utilize alarms that are tamper-proof and specifically do not have an “ON/OFF” button or switch accessible to resident. The alarm’s battery cover should also be tamper-proof to eliminate the possibility of a resident or “buddy” from removing batteries, which will disable the alarm.
  • Make it a priority for nurses to respond immediately to sounding alarms; develop a fall alarm-response protocol, which will help ensure that alarms are recognized and promptly answered
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