Failure to Keep Call Lights Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call lights were within reach, as required to keep the environment free from accident hazards and provide adequate supervision to prevent accidents. The resident had multiple significant diagnoses, including hemiparesis/hemiplegia following a stroke, neuromuscular bladder dysfunction, unsteadiness on feet, and major depressive disorder. A recent MDS documented a BIMS score of zero, indicating severely impaired cognition, and showed the resident required setup or cleanup for eating, substantial/maximal assistance with bathing and oral care, and was dependent on staff for toileting. The MDS also documented impairment of one side of the upper and lower extremities and that the resident had not had any falls since admission. A Falls Care Area assessment documented that the falls CAA triggered due to a fall and medications that could increase fall risk, and that the resident would receive medications as ordered, assistance with ADLs, nonskid footwear, and therapy. The care plan included directions for staff to place frequently used items within reach at night, re-educate the resident on call light use, place nonskid strips around the bed, address fall risk due to unawareness of limitations, and use bolsters on the bed. On the survey date, the resident was observed lying in bed with her upper body and right arm leaning to the right and her legs on the left side of the bed, while she yelled out for help to be repositioned. At that time, her portable box call light was on the bedside table and her cord call light was wrapped around the overhead table and caught under the bed, so neither call light was within her reach. Staff interviews confirmed that the resident’s portable call light should be on the overhead table where she could reach it, and that either the portable or cord call light should always be within reach of the resident. An administrative nurse also stated that residents’ call lights should be placed within their reach. The facility’s Falls policy stated that each resident would receive services and care to ensure the environment remained as free from accident hazards as possible and that each resident would receive adequate supervision and assistive devices to prevent accidents, which was not followed in this instance when the resident’s call lights were not accessible.
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