Call Light Not Accessible to Resident with High Fall Risk
Penalty
Summary
Facility staff failed to ensure that a resident's call light was within reach, as required by the resident's care plan and facility policy. During an observation, the resident was seen searching for her call light, which was found wedged between the mattress and fitted sheet, out of her reach. The Assistant Director of Nursing confirmed that the call light was not accessible and acknowledged that it should have been within the resident's reach for safety reasons. The Director of Nursing also stated that call lights should be accessible to residents to allow them to request assistance in a timely manner. The resident involved had a history of neurocognitive disorder with Lewy bodies, adult failure to thrive, a history of falls, and severely impaired cognition. Her care plan specifically identified her as being at high risk for falls and required that her call light be placed within reach and that she be encouraged to use it for assistance. The facility's policy also required staff to ensure the call device was accessible before leaving the room. The failure to follow these protocols resulted in the resident being unable to call for help when needed.
Plan Of Correction
F550 Corrective Action Assigned CNA was inserviced 1:1 by DSD on 05/27/25 on Resident Rights, including the importance of keeping the call light within reach at all times. Assigned LVN was inserviced 1:1 by DSD on 05/27/25 on Resident Rights, including the importance of keeping the call light within reach at all times. Identification of Others at Risk All residents of this facility have the potential to be affected by this deficiency. The DSD has made observation rounds on 05/27/25 on call lights being within reach. All call lights were within reach. Process to Prevent Recurrence The DON and DSD have inserviced nursing and facility staff between 05/27/25 and 05/30/25 on Resident Rights, including the importance of keeping the call light within reach at all times. The Guardian Angels will observe the placement of the call lights during their routine rounds. Results will be reported to the Administrator for any needed follow-up. Monitoring Process The Administrator will provide results of the observation rounds to the QA&A committee during the monthly meeting. The Quality Assessment & Assurance and Continuous Quality Improvement Committee will monitor compliance by review of findings and actions/resolutions taken during the monthly meeting for 3 months. Complete Date: 06/12/25