Inaccessible Bathroom Call Light for Resident with Fall Risk
Penalty
Summary
The facility failed to ensure that a working call system was available and accessible in the bathroom and bathing area for a resident with moderate cognitive impairment and mobility issues. Observation and interviews revealed that the emergency call light cord in the resident's bathroom was positioned three feet above the floor, making it unreachable for a resident who might fall. A housekeeper confirmed that if the resident were to fall, she would not be able to access the call light and would have to wait until staff made rounds or heard her. The maintenance director acknowledged that bathroom call lights needed to be accessible at floor level, and the assistant director of nursing stated that all staff were responsible for ensuring call lights were in place and accessible. Record review indicated that the resident was at risk for falls and required supervision or assistance for toileting and ambulation. The facility's policy required that call lights be within reach and accessible to residents, and that residents be instructed on their use. Despite this policy, the call light in the resident's bathroom was not accessible, as confirmed by multiple staff interviews and direct observation.