Failure to Keep Resident Call Light Within Reach
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was kept within reach as required by the resident’s care plan and facility policy. The resident had diagnoses including Alzheimer’s disease, hypertension, depression, and anxiety, with a BIMS score of zero indicating severely impaired cognition, and was dependent on staff for all ADLs. The Falls CAA documented a prior minor-injury fall and that fall precautions were in place with close monitoring. The care plan included an intervention, initiated in December 2022, to keep the resident’s call light within reach and answer it promptly, along with multiple fall-related interventions following falls in August 2025 and September 2025, and documentation in May 2026 that the resident was at risk for falls due to poor safety awareness and impulsiveness. On the survey date, the resident was observed lying in bed on her back with eyes open, covered with blankets, and yelling out, while the call light was found behind the headboard of the bed and not within reach. A CMA stated that residents should always have their call lights within reach and moved the resident’s pancake light onto her abdomen. Subsequent interviews with a licensed nurse and an administrative nurse confirmed that residents’ call lights should be placed where they are reachable by the resident. The facility’s Call Light Answering policy required staff to answer call lights within 15 minutes, respond to emergency lights immediately, and check to ensure the call light was within the resident’s reach, which was not followed in this instance.
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.