Failure to Ensure Call Light Accessibility for Resident with High Fall Risk
Penalty
Summary
A deficiency occurred when staff failed to ensure a resident had access to her call light, which was required for her to communicate her needs. The resident had multiple medical diagnoses, including muscle weakness, overactive bladder, a need for assistance with personal care, a history of falling, and a cognitive communication disorder. Her care plan specifically instructed staff to keep the call light within reach at all times due to her high risk for falls and need for substantial to maximal assistance with activities of daily living. Despite these documented needs and instructions, observations showed that the resident's soft-touch call light was placed on a bedside table across the room, out of her reach, while she was in bed on multiple occasions. Interviews with facility staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that the expectation was for call lights to be within reach of residents at all times and checked each shift. The facility's Fall Management System policy also required appropriate equipment and interventions to ensure resident safety and prevent falls. The failure to follow these protocols and care plan instructions resulted in the resident being unable to communicate her needs, constituting a deficiency in reasonably accommodating her needs and preferences.