Failure to Ensure Call Light Accessibility for Resident at Risk for Falls
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to implement a comprehensive, person-centered care plan for a resident with chronic kidney disease and dementia who was at increased risk for falls. Despite the care plan specifying that the resident's call light should be kept within reach and that the resident should be encouraged to use it for assistance, multiple observations on different occasions showed the call light was out of reach. Staff interviews confirmed that the resident had experienced recent falls and was capable of using the call light, and staff were expected to ensure the call light was accessible during every room entry. However, staff acknowledged that the call light was not always within the resident's reach, as required by the care plan.