Failure to Ensure Accessible and Functional Call Light for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident had a functional call light system within reach, as required by the resident’s care plan and facility policy. The resident had an MDS BIMS score of 14, indicating intact cognition, and was dependent on staff for toileting, hygiene, bathing, lower body dressing, and transfers. The care plan identified the resident as at risk for falls related to a recent hospitalization and specified that the call light must be within reach. On the morning of the incident, staff heard someone calling for help and found the resident sitting on the floor with her back against her room door and feet extended. The resident reported she had attempted to use her call light for assistance to the bathroom, but the call light cord was caught in the hinge of the bed rail and could not be triggered when pulled. The incident documentation and subsequent interviews confirmed that, although the call light appeared to be within reach from the resident’s recliner, the cord had fallen and become entrapped under the bed grab bar, preventing activation. The resident then attempted to walk without her walker to retrieve her cell phone, which was charging on the sink counter, in order to call the facility for help, and she fell. Later observation showed the resident’s cell phone on a table across the room under a window, with a long cord attached but not within reach. The DON acknowledged that staff were expected to ensure call lights were within reach and not wrapped around bed rails, and the facility’s policy stated that all resident call lights must be accessible, functional, and answered promptly to maintain resident safety, dignity, and well-being. Despite these expectations and care plan interventions, the resident’s call light was not effectively accessible at the time assistance was needed.
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