Failure to Keep Call Light Within Reach for High-Risk Resident
Penalty
Summary
The facility failed to ensure that the call light was kept within reach for a resident who was at high risk for falls and required substantial assistance with mobility and activities of daily living. The resident had a history of muscle weakness, abnormal gait, impaired vision, moderate cognitive impairment, and was assessed as high risk for falls. The care plan specifically included an intervention to keep the call light within easy reach and encourage its use for assistance. During an observation, the call light was found on the floor, out of the resident's reach, and staff confirmed that it should have been accessible at all times. Interviews with facility staff, including the Infection Preventionist and the DON, confirmed that ensuring the call light is within reach is a staff responsibility and is especially important for residents with cognitive or physical impairments. The facility's policy also required that each resident be provided with a means to call staff for assistance from their bed and other areas.