Call Light Not Kept Within Reach for Resident with Fall Risk
Penalty
Summary
A deficiency was identified when a resident's call light was found on the floor, out of reach, during an observation in the resident's room. The resident had a history of hypertension, falls, and severe cognitive impairment, requiring substantial assistance with activities of daily living. The resident's care plan specifically indicated that the call light should be kept within reach. During the observation, the Director of Staff Development confirmed that the call light was not accessible to the resident and acknowledged the importance of keeping it within reach to ensure the resident could request assistance as needed. Interviews with facility staff, including the Director of Nursing, further confirmed the necessity of maintaining the call light within easy reach for residents, especially those at risk for falls or with impaired cognition. A review of the facility's policy on answering call lights also stated that the call light should always be within easy reach when a resident is in bed or confined to a chair. The failure to ensure the call light was accessible constituted a breach of both the resident's care plan and facility policy.