Failure to Maintain Accessible Call Lights, Functional Equipment, and Supervision for Residents at Risk for Falls
Penalty
Summary
The deficiency involves the facility’s failure to maintain call lights within reach for multiple residents identified as at risk for falls, failure to ensure essential equipment was functioning, and failure to supervise a resident at risk for falls while outside smoking. One resident with dementia, bipolar disorder, end stage renal disease, difficulty walking, and a high fall risk score had a care plan requiring the call light to be within reach and prompt response to requests for assistance. This resident had seven documented falls over a 24‑month period, and the facility could not produce the fall occurrence note for one of those falls. During observation, the resident was lying in bed on a bordered mattress with the call light on the floor and out of reach, while alone in the room. The CNA assigned to this resident acknowledged the call light had been on the floor and confirmed the resident could not transfer independently. Another resident with hemiplegia/hemiparesis, gait imbalance, moderate cognitive impairment, and a documented fall risk had a care plan requiring the call light to be within reach and the bed to be in the low position. This resident had a recent fall and was described by the restorative nurse as intermittently confused and needing assistance with transfers but not always asking for help. On observation, the resident was in bed with the call light tied to the side rail and the button dangling below the bed, out of sight, and the bed was at about knee height rather than in the lowest position. When the assigned CNA attempted to lower the bed, it was discovered that the bed was unplugged and, even after plugging it in, the bed still did not work, and the CNA stated the bed was not working. A third resident with dementia, osteoarthritis of the hip, weakness, gait/balance problems, and poor safety awareness had a care plan requiring the call light to be within reach and use of a walker as a fall prevention intervention. This resident experienced an unwitnessed fall on the smoking patio, reporting that she lost her balance while turning and fell into the bushes during a smoke break, with no staff present to witness the event. The restorative nurse stated the resident is alert, ambulatory with a walker, has gait imbalance, and requires supervision. During observation, this resident was sitting on the bed with the call light tied to the side rail and hanging near the floor. The CNA assigned to this resident confirmed the call light was wrapped around the bed rail and hanging down, acknowledged that call lights should be across the bed within reach, and noted that not all facility call lights have clips. The facility’s fall prevention program requires safety interventions to be implemented and maintained for residents at risk, malfunctioning equipment to be reported or removed from service, and residents to be checked regularly to assure safe positioning.
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