Failure to Respond to Call Light and Supervise Resident Results in Fall and Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and a timely response to a call light for a resident with multiple risk factors for falls. The resident, who had diagnoses including Parkinson's disease, ataxia, osteoporosis, and moderate cognitive impairment, was care planned as a fall risk and required moderate assistance with transfers. On the morning of the incident, the resident activated her call light and called for help while sitting on the side of her bed. After waiting without receiving assistance, she attempted to get up on her own and subsequently fell, resulting in a sprained left ankle. The fall was unwitnessed and occurred during a shift change, a period when staffing was affected by a CNA no-show. Multiple staff interviews confirmed that the call light was on when the resident was found on the floor, but staff were unable to determine how long it had been activated. Video footage reviewed by facility leadership and the resident's responsible party showed the resident calling for help and falling after not receiving timely assistance. The facility's incident and accident reports indicated a pattern of unwitnessed falls during the night shift in the weeks surrounding the incident. At the time of the fall, the resident was found on the floor by incoming CNAs, who notified the nurse on duty. The nurse assessed the resident, who initially denied injury, but later complained of ankle pain and was sent to the hospital, where a sprain was diagnosed. The failure to respond promptly to the call light and provide adequate supervision during a known high-risk period directly contributed to the resident's avoidable fall and injury.