Failure to Ensure Call Light Accessibility for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident's call light was within reach, as required by the resident's care plan and facility policy. The resident in question had diagnoses including dementia, muscle weakness, and a history of repeated falls, and was assessed as having severe cognitive impairment and a high risk for falls. The care plan specifically instructed staff to keep the resident's soft-touch call light within reach at all times. However, during multiple observations, the call light was found on the floor underneath the bed, out of the resident's reach, while the resident was in bed. Interviews with facility staff confirmed that the call light should have been placed within easy access for the resident, in accordance with both the care plan and facility policy. The failure to properly position the call light did not align with the instructions to provide a safe care environment and appropriate assistive devices for residents at risk for falls. This inaction placed the resident at risk for preventable accidents and injuries.