Failure to Keep Call Lights Within Reach for Residents at Risk for Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ call lights were within reach as required by their individualized care plans. For one resident admitted with a cerebral infarction resulting in left-sided hemiplegia, dementia, impaired mobility, and a history of falls, the care plans directed staff to encourage the resident to use the call bell for assistance and when attempting to get out of bed. During observation, this resident was found lying in bed with the call bell hanging on the wall behind the bed, draped over sconce lights, and the cord positioned behind the headboard. When interviewed, the resident reported frequent falls and, when asked how to call the nurse, looked around for the call bell and attempted to reach behind the bed. The resident was only able to grab the cord, which was stuck behind the bed and not accessible until a GNA entered, identified that the cord was stuck under the bed, and raised the head of the bed to free it. A second resident, in the facility since 2017, had diagnoses including a non-displaced right humerus fracture, osteoarthritis, obsessive-compulsive disorder, unspecified dementia, and repeated falls, with documented falls resulting in a head hematoma with laceration and a right humerus fracture. This resident’s care plans included being at risk for falls with an intervention to keep the call light within reach at all times while in the room, and an additional plan for an actual fall with injury that included educating the resident to use the call bell when getting out of bed. On three separate observations, the resident was found lying in bed with the call bell not within reach; instead, it was wrapped around the back, bottom of the quarter side rail and lying on the floor. The DON, present during one of these observations, acknowledged that the call bell should not be on the floor and was informed of the prior similar observations.
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