Call Light Not Kept Within Reach for Fall-Risk Resident
Penalty
Summary
Surveyors identified a deficiency related to accident prevention when a resident at risk for falls did not have their call light within reach. During an observation and interview on January 30, 2026, at 8:17 a.m., the resident’s call light button was seen hanging on the left side of the bed, out of the resident’s reach. The resident reported that she normally used the call light when she needed staff assistance but could not locate it at that time. The resident’s admission record showed diagnoses including traumatic subdural hematoma, history of fall, and abnormality of gait. Her care plan documented that she was at risk for falls related to a history of falls prior to admission and unsteady gait/balance, with an intervention specifying that the call light should be placed within reach. At 8:30 a.m. the same day, a CNA assigned to the resident acknowledged during an interview in the resident’s room that she had missed the call light button and that it had been left hanging on the left side of the bed, not within the resident’s reach. The CNA stated the call light should have been positioned and secured in front of the resident. The DON later stated that fall-risk residents are discussed during the morning huddle and acknowledged that a call light not within reach may present a potential risk for falls. Review of facility policies titled “Call Light Accessibility and Timely Response” and “Fall Prevention Program,” both dated December 19, 2022, showed that staff are required to ensure call lights are within reach and secured, and that fall prevention measures include ensuring call lights are within reach, which was not followed in this instance.
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