Failure to Ensure Call Light Accessibility Resulted in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to implement a fall prevention intervention by not ensuring a resident's call light was within reach after the resident was positioned in his recliner. The resident, who was able to call out for help and use his call light, was found on the floor after attempting to reach for his call light, which was not accessible to him at the time. The incident was identified after staff heard the resident calling for help and found that he had fallen while trying to access his call light from his recliner. Review of the incident revealed that the certified nurse aide responsible for the resident did not position the call light within the resident's reach after transferring him to the recliner, contrary to facility policy and training. Observations of other residents confirmed that staff generally ensured call lights were accessible, but in this specific case, the failure to do so directly led to the resident's fall. The root cause was identified as the staff member's failure to follow established fall prevention protocols.