Failure to Provide Adequate Supervision and Accessible Call Light Leads to Resident Fall
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including encephalopathy, dementia, gait and mobility abnormalities, and cognitive communication deficit, was left unsupervised and without access to a call light after returning to his room from the nurses' station. The resident required substantial to maximal assistance for transfers and was identified as a fall risk, with care plans specifying the need for a two-person assist and a reachable call light at all times. Despite these documented needs, the resident was able to wheel himself back to his room unaccompanied, and the call light was not within his reach. As a result of these lapses, the resident attempted to transfer himself from his wheelchair to his bed without assistance, leading to a fall. The fall was unwitnessed, and the resident sustained an abrasion to the top of his left hand and reported bilateral foot pain. Observations and interviews confirmed that the call light was out of reach at the time of the incident, and staff acknowledged that the call light should have been accessible and that the resident required close monitoring and assistance for transfers. Facility policies reviewed indicated that residents confined to a chair or bed should have the call light within easy reach, and that interventions should be tailored to individual fall risks. Multiple staff interviews corroborated that the resident was a known fall risk and typically required close supervision, yet these interventions were not consistently implemented, directly contributing to the resident's fall and resulting injuries.