Failure to Ensure Call Lights Accessible for Residents at Risk for Falls
Penalty
Summary
The facility failed to ensure that call lights were accessible and within reach for two of three residents reviewed for falls. One resident with Parkinson's disease and dementia, who required extensive assistance for all transfers and was at risk for falls, was observed sitting in his wheelchair with his call light on the floor behind him, out of reach. The resident requested assistance from the surveyor to pick up a glass, and stated he did not have his call button. A nursing assistant confirmed that the call light should have been within the resident's reach due to his agitation and risk of self-transfer. Another resident with Alzheimer's disease, severe cognitive impairment, and limited physical mobility was observed sitting in a recliner with her call light on the floor next to her foot, not within reach. She requested help from the surveyor to pick up items from the floor and explained she could not find her call button. A nursing assistant confirmed the call light was not within reach and should have been accessible. The facility's policy requires staff to ensure call lights are within reach and secured as needed, but this was not followed in these instances.