Failure to Ensure Call Light Accessibility for Residents at Risk for Falls
Penalty
Summary
The facility failed to ensure that the call light was kept within reach for two residents, both of whom were identified as being at risk for falls. For one resident, who had diagnoses including osteoarthritis and psychosis and required supervision or assistance for mobility, the call light was repeatedly observed to be out of reach—either hanging behind a bedside dresser or disconnected and coiled on the dresser. Staff interviews confirmed that the call light was not accessible, and the resident was observed getting out of bed without assistance to press the call button on the wall, while not wearing appropriate footwear, despite care plan interventions specifying that the call light should be within reach and proper footwear should be used. Another resident, with multiple diagnoses including diabetes, congestive heart failure, osteoarthritis, muscle wasting, and dysphagia, and who was non-ambulatory and used a wheelchair, was also found to have the call light out of reach. The call light was observed hanging behind the head of the bed, inaccessible to the resident, who confirmed she could not reach it and requested assistance. Staff acknowledged that the call light was not within reach and that this prevented the resident from being able to call for help when needed. Review of facility policies indicated that staff were required to ensure call lights were accessible to residents at all times, particularly for those at risk for falls, and that this was to be checked with each interaction in the resident's room. Despite these policies and individualized care plan interventions, staff failed to maintain call light accessibility for both residents, as confirmed by multiple observations and staff interviews.