Failure to Implement Fall Prevention Interventions and Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that fall prevention interventions were consistently implemented for multiple residents identified as being at risk for falls. One resident with a history of stroke, hemiplegia, dementia, and other significant medical conditions was care planned to have a bed alarm in place due to her high fall risk. However, during observation, the bed alarm was found on top of the blankets and not under the resident, rendering it ineffective. This same resident had a recent unwitnessed fall in her room, and documentation indicated that the bed alarm was not activated at the time of the incident. Two additional residents, both with dementia and a history of falls, were observed in their rooms without their call lights within reach. One resident's call light was on an empty bed next to him, and he was unable to locate it, stating he had previously fallen while trying to get up. The other resident's call light was found on the floor, out of reach, and he was unaware of its location. Staff interviews confirmed that call lights should be accessible to residents at all times, and care plans for both residents specified that call lights should be within reach and that residents should be encouraged to use them for assistance. The facility's own policies on fall prevention and call light accessibility require that interventions such as bed alarms and accessible call lights be in place for residents at risk of falls. Despite these policies and individualized care plans, staff failed to ensure that these safety measures were consistently implemented, resulting in residents being left without necessary fall prevention interventions.