Failure to Implement Fall Risk Intervention: Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to implement a person-centered care plan intervention for a resident with dementia and a history of falls. The care plan required that the call light be kept within the resident's reach at all times, with additional interventions to remind and educate the resident to use the call light for assistance. Despite these documented interventions, multiple observations by the surveyor revealed that the call light cord was not within the resident's reach while the resident was in bed or seated in a reclining chair. The red string attached to the call light box was observed hanging at the foot of the bed or on the bed, out of the resident's immediate reach during several checks throughout the day. Interviews with facility staff confirmed that the resident was able to ambulate with a rolling walker and would attempt to get up independently, and that the resident knew how to use the call light. Staff also acknowledged that the call light should be within the resident's reach as part of the care plan interventions. The medical record indicated that the resident had experienced multiple falls during their stay, and the care plan interventions were specifically designed to address this risk. However, the facility did not consistently ensure that the call light was accessible to the resident as required by the care plan.