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F0919
D

Call Light Not Kept Within Reach for Bedbound Resident

Inverness, Florida Survey Completed on 05-15-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a resident, who was at risk for falls and required a Hoyer lift for mobility, did not have consistent access to her call light while in bed. The resident reported not having a call light and stated she was instructed to call out verbally for assistance. Multiple observations confirmed that the call light was placed out of reach, including being on the bedside table, inside a drawer, and clipped to the drawer pull, none of which were accessible to the resident from her bed. Photographic evidence was obtained during these observations. Interviews with staff revealed that the call light was intentionally clipped to the bedside table by a CNA during care, and both the RN and DON acknowledged that the resident would not be able to reach the call light in those locations. The resident's care plan specifically required the call light to be kept within reach due to her fall risk, and facility policy mandated that call lights be accessible to residents in bed or confined to a chair. Despite these requirements, the call light was repeatedly found out of reach, and the resident was unable to summon assistance as intended.

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