F0689

D

Failure to Maintain Call Light Within Reach for High Fall-Risk Resident

Oneida, New York Survey Completed on 01-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident at high risk for falls had their call light within reach as care planned, resulting in an environment that was not as free of accident hazards as possible. The resident had right-sided paralysis and weakness, severely impaired cognition, and required dependence for dressing, personal hygiene, and bed mobility. The resident’s comprehensive care plan, initiated due to high fall risk related to deconditioning, included interventions such as ensuring the call light was within reach, encouraging use of the call light for assistance, and prompt staff response. A fall risk assessment also documented the resident as a fall risk, with intermittent confusion, chairbound status, and incontinence.

Despite these documented interventions, surveyors repeatedly observed the resident lying in bed with the call light on the floor under the top part of the bed and not within reach on multiple dates and times. Staff interviews confirmed that the resident was care planned for falls and that all staff were responsible for ensuring call lights were within reach. A CNA who cared for the resident during the survey week acknowledged the resident was care planned for falls and stated the call light should always be within reach, suggesting a clip could be used to prevent it from falling. An LPN and an RN manager both confirmed the resident was a fall risk with care plan interventions that included having the call light within reach and that all staff entering the room were responsible for ensuring this, but they did not recall seeing the call light on the floor. These observations and statements demonstrate that the care-planned intervention to keep the call light within reach was not consistently implemented.