F0689

G

Failure to Timely Respond to Call Light Resulting in Fall With Rib Fractures

Normal, Illinois Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to respond to a resident’s call light in a timely manner, resulting in a fall with injury. A cognitively intact resident (R1), who used a mechanical lift and had a pressure-relieving mattress, activated the call light to request assistance in retrieving popcorn from the floor. R1 and a family member reported that the call light remained on for approximately 40 minutes without response. During this time, R1 attempted to reach the popcorn independently, rolled out of the regular-height bed, and was found lying face down between the bed and the wall. R1’s roommate yelled for help, and a CNA entered the room and observed R1 on the floor. Progress notes document that R1 complained of pain “all over,” 911 was called, and R1 was transported to a local emergency department.

Emergency department records document nondisplaced right lateral fifth through ninth rib fractures and nondisplaced acute fractures of the anterior left sixth, seventh, eighth, and tenth ribs. R1’s care plan included interventions to keep the bedside table next to the bed within reach and to keep the call light within reach at all times. Staff interviews revealed that call lights sometimes go unanswered for 20 to 40 minutes, particularly on evening, dinner, and bedtime shifts, and that there were often only two CNAs on duty for the unit, with one CNA occasionally off the unit accompanying another resident to appointments. Nursing and rehabilitation staff acknowledged that at times they could not get to residents soon enough after call lights were activated. The facility’s call light policy required that call lights be available at each bedside and that response times be a priority, and the incident/accident policy required appropriate and immediate interventions and corrective actions to prevent recurrences.