Failure to Ensure Call Lights and Pad Sensors Were Within Reach for High-Risk Residents
Penalty
Summary
The facility failed to ensure that pad sensors and call lights were within reach for three residents who were assessed as high risk for falls and had significant cognitive and physical impairments. For one resident with dementia, osteoporosis, and a traumatic fracture, the care plan required the call light to be kept within easy reach and encouraged its use for assistance. However, during observation, the pad sensor was found hanging on the left siderail, out of reach, despite the resident being stronger on the right side. The assigned CNA confirmed the resident could not reach the pad sensor and acknowledged it should have been placed on the resident's strong side. Another resident with dementia, muscle weakness, and left-sided hemiparesis was also found with the call light on the floor on the left side of the bed, which was not accessible due to the resident's inability to use the left arm and hand. The LVN present confirmed the call light should have been placed on the resident's strong side for timely assistance. Both the Director of Nursing and the LVN stated that facility policy requires call lights to be within easy reach of residents, especially those at high risk for falls. A third resident with metabolic encephalopathy, Parkinson's disease, and muscle weakness was observed with the call light on the floor and not within reach. Staff interviews confirmed the call light should not be on the floor due to infection control and accessibility concerns. Facility policies reviewed indicated that residents must be provided with a means to call for assistance from their bed, and alternative communication methods should be documented in the care plan if needed. These observations and interviews demonstrated a failure to follow care plans and facility policies regarding resident safety and supervision.