Failure to Keep Call Bell and Essential Items Within Reach for High-Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light and commonly used items were kept within reach as required by the individualized care plan. The resident was admitted with diagnoses including unspecified dementia, repeated falls, and multiple sclerosis, and had a care plan initiated in November 2024 identifying an actual fall and risk for falls related to generalized weakness and gait/balance problems. The care plan included an intervention to keep commonly used articles, such as the call bell and TV remote control, within easy reach. During an observation on 1/12/26 at 11:26 AM, the resident was found lying in bed with the call bell cord hanging on the wall, out of reach, and the over-bed tray table positioned by the window, also out of reach, with water, sandwiches, and the TV remote on it. When asked, the LPN Unit Manager had to look around the bed to locate the call bell on the wall and then placed it on the bed and moved the tray table within reach. On subsequent observations on 1/13/25 at 9:35 AM and 1/13/26 at 12:25 PM, the call bell cord with attached call bell was again found lying on the floor, out of the resident’s reach, and this concern was shown to staff and reported to an RN, demonstrating repeated failure to maintain the call bell within reach as care planned.
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