Failure to Ensure Call Light Accessibility for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident identified as high risk for falls had their call light within reach, as required by facility policy. The resident had a history of chronic kidney disease, altered mental status, severely impaired cognition, and a history of falls, and was assessed as high risk for falls. The care plan included interventions such as reminding the resident to call for staff assistance and ensuring the call light was accessible. However, during observation, the call light was found removed from the wall and placed on a bedside table, out of the resident's reach while she was sitting in a recliner at the back of the room. Staff interviews confirmed that call lights should always be placed within easy reach of residents unless a specific preference is documented, which was not the case for this resident. The facility's policy also required that call lights be accessible to residents at all times. The failure to ensure the call light was within reach was verified by both nursing and administrative staff, and there was no documentation indicating the resident had requested the call light be placed elsewhere.