Failure to Ensure Call Light Accessibility and Supervision for Fall-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to prevent falls for a resident with a history of repeated falls, chronic pain, and moderate cognitive impairment. The resident's care plan included interventions such as ensuring call light attendants were in place and functioning, and staff were to ensure the resident was in bed or a recliner with the call light accessible. Despite these interventions, after a fall in which the call light was found unplugged and the resident was unable to call for help, new interventions were added to ensure the call light was properly connected and functioning at all times. However, during a subsequent observation, the resident was found sitting in a wheelchair with both call lights out of reach—one hanging off a recliner and another in a bedside table drawer. An LPN entered and exited the room without checking the call light placement or offering assistance to the resident, and later stated being unaware of the resident's call light needs. The facility's policy required staff to monitor and document the effectiveness of interventions and to carry out physician orders, but these were not followed, resulting in inadequate supervision and failure to maintain a hazard-free environment for the resident.