Failure to Keep Call Lights Within Reach for Two High Fall-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that call light devices were placed within reach for two residents who were care planned to have accessible call lights as part of their fall prevention interventions. One resident had diagnoses including pulmonary embolism, Type 2 DM, and COPD, with a BIMS score of 11 indicating moderately impaired cognition and requiring substantial/maximal assistance with multiple ADLs. This resident’s care plan for fall risk specified that a working and reachable call light must be ensured and that the resident’s call light should be within reach with encouragement to use it for assistance. The resident was also listed on the unit’s high fall-risk list and enrolled in a falling leaf program with an intervention to educate on calling for assistance prior to transfers. The second resident had diagnoses including hypertension, Type 2 DM, and osteoarthritis, with a BIMS score of 9 indicating moderately impaired cognition and requiring partial/moderate assistance with toileting and bathing. This resident’s fall risk care plan also required a working and reachable call light and personal items within reach, and directed staff to ensure the call light was within reach and to encourage its use for assistance. During a surveyor observation with a CNA, both residents were found lying in bed and unable to access their call devices; one resident stated he did not know where his call device was, and the CNA found both residents’ call lights on the floor, not within their reach. Facility policies and the CNA job description required that residents with the ability to use a call device have the nurse call light system available at all times and within easy accessibility, and that staff answer call lights and provide for resident comfort and safety, but these requirements were not met for the two residents at the time of observation.
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