Call Light Not Kept Within Reach for Resident at Risk for Falls
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as required by facility policy and the resident's care plan. The resident, who had a history of muscle wasting and atrophy, chronic pain syndrome, unsteadiness, history of falls, dementia, lack of coordination, and Alzheimer's disease, was identified as being at risk for falls and required encouragement to call for assistance. On multiple occasions, observations revealed the resident lying in bed with the call light placed on a table at the foot of the bed, out of her reach. When asked, the resident was unable to locate or access the call light. Staff interviews confirmed that the call light was not within reach and acknowledged that it should have been accessible to the resident.