Failure to Ensure Call Light Accessibility for Residents at Risk of Falls
Penalty
Summary
The facility failed to ensure that the call light system was accessible to three residents who were identified as being at risk for falls and requiring assistance with activities of daily living. Observations revealed that the call light buttons for these residents were either on the floor or otherwise out of reach while the residents were in bed. Staff interviews confirmed that the call lights were not placed within reach after care was provided, despite care plans specifying that call lights should be accessible to the residents at all times. The residents involved had varying levels of cognitive impairment and physical assistance needs, with documented histories of falls and unsteadiness. Record reviews showed that each resident's care plan included interventions to keep the call light within reach due to their fall risk and need for assistance. Staff acknowledged during interviews that the call lights were not accessible and recognized the importance of having them within reach. The facility's in-service training materials also specified proper placement of call lights, but there was no formal policy on call light accessibility. The deficiency was identified through direct observation, staff interviews, and review of resident records.