Failure to Implement Care-Planned Fall Interventions Related to Call Light Access
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to implement fall-prevention interventions as care planned for a resident with significant neurological and mobility impairments. The resident’s diagnoses included hemiparesis, hemiplegia, dementia, and cerebrovascular accident, and a recent MDS documented intact cognition with a history of one non-injury fall. A Falls CAA identified the resident as at risk for falls due to unsteady balance, history of falls, and psychotropic medications. The care plan included interventions such as anticipating and meeting needs, following the facility’s fall protocol, educating the resident and family about safety, providing prompt response to requests for assistance, ensuring the call light was within reach and encouraging its use, keeping the resident’s chair reclined when not eating, and ensuring right lateral support was in place. Despite these care-planned interventions, the facility did not consistently ensure the resident’s call light was within reach. A Fall Note documented that dietary staff witnessed the resident fall over the side of his wheelchair to the floor, resulting in skin tears to the left knee, right ankle, and left thumb, and a Fall Risk Assessment on the same date identified the resident as a high fall risk. On two separate observations later in the month, the resident was seen reclined in a Broda chair in his room with the call light lying behind the bed and not within his reach. During interviews, a CNA, a licensed nurse, and an administrative nurse all stated that staff had access to care plans, that fall interventions were found in those care plans, and that call lights should be within reach of residents, including this resident. The facility’s Managing Falls and Fall Risk policy stated that staff would identify and implement interventions based on evaluations and current data to try to prevent falls and minimize complications, but the call light intervention was not implemented as planned.
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.