Failure to Promptly Respond to Call Light for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to promptly respond to a call light for a newly admitted resident who had been identified as a high fall risk and required staff supervision due to unsteady gait and safety concerns with transfers and ambulation. The facility’s undated Call Light System policy requires staff to respond promptly when a call light is activated, address the resident’s need or request, and, if unable, locate another staff member who can meet the need. The resident was admitted and within approximately five hours sustained an unwitnessed fall with suspected injury and loss of consciousness, with nursing notes documenting a bleeding skin tear on the left arm and an emergency transfer to the hospital. The incident report shows that at approximately 4:25 p.m., a CNA going to respond to the resident’s bathroom call light found the resident on the bathroom floor, unresponsive and lying prone. Interviews revealed that one CNA was at the nurses’ station at the time of the fall and was not paying attention to the call light panel, assuming most residents were in the dining room. Another CNA observed the resident’s call light blinking and sounding while passing meal trays and assumed the CNA at the nurses’ station would answer it, continuing to pass trays. When this CNA later returned to the hall, the call light was still flashing and sounding; she then entered the room and found the resident on the floor, estimating about seven minutes had passed from when she first noticed the call light. The LPN reported arriving to find the resident unresponsive with a bleeding skin tear and contacting EMS. A brain scan documented acute swelling and bleeding on both sides of the brain as a result of the fall. The DON stated that newly admitted residents are treated as fall risks and that his expectation is that any staff member aware of a call light should respond immediately, or within five to eight minutes if actively assisting another resident, and that communication between CNAs should have ensured the call light was answered.
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