Call Light Inaccessibility for High Fall Risk Resident
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including dementia, anxiety, depression, schizophrenia, morbid obesity, and a recent left lower leg fracture, was found unable to access the call light in her room. The resident, who had a moderate cognitive deficit and was assessed as a high fall risk with two recent falls, was observed sitting on her bed with the call light hanging from the wall and lying on the floor between the bed and the wall. The resident reported being unable to reach the call light and demonstrated her inability to do so during the observation. Further observation and interview with an LPN confirmed that the call light was indeed inaccessible, as it was stuck between the bed and the wall. The LPN had to physically crawl over the bed and stretch to retrieve the call light and make it accessible to the resident. This incident was documented as a failure to ensure that call lights were accessible to residents, as required, and was identified during an investigation under a specific complaint number.