Failure to Keep Call Light Within Reach for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow its Call Light Policy by not ensuring a resident’s call light was within easy reach. A female resident with secondary parkinsonism, Alzheimer’s disease, type 2 diabetes, anxiety, bipolar disorder, hypertension, gout, hyperlipidemia, and hypothyroidism was re-admitted to the facility and had documented ADL self-care deficits, unsteady gait, impaired mobility, cognitive impairment, and dependence on staff for ADLs and transfers. Her fall care plan, which identified her as high risk for falls with poor safety awareness and cognitive deficits, included an intervention requiring that her call light be kept within reach and that she be encouraged to use it for assistance, with prompt response to all requests. A Call Light Ability Screen documented that she was able to follow instructions and demonstrate use of the call light and was able to use it. During room rounds on multiple days, surveyors observed that the resident’s call light was not accessible. On one occasion, the call light string was on top of the bedside table and not within the resident’s reach while she was awake and resting in bed; when asked, a CNA stated it was placed there because the resident “always plays with the call light” and did not answer how the resident could request assistance when it was out of reach. On another observation, while the resident was in bed eating breakfast, the call light cord was positioned away from her with the end of the string on the floor, and the CNA stated the resident likely threw it onto the floor, while also confirming the resident uses the call light to request assistance. Floor mats were present on both sides of the bed to prevent injury in the event of a fall. Other interviewed staff, including an RN, an LPN, and another CNA, stated that call lights should always be within residents’ reach so they can call for assistance and that failure to do so could lead to falls, and they described the importance of placing or clipping the call light close to residents. The facility’s Call Light Policy required that residents capable of using the call light appropriately have their call light accessible at all times.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.