Failure to Ensure Accessible Call Light Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to prevent a fall by ensuring a resident’s call light was within reach and that adequate supervision was provided. The resident had hemiplegia and hemiparesis affecting the left non-dominant side and was moderately cognitively impaired, scoring 9 out of 15 on the BIMS. The resident reported that staff sometimes attached the call light to his left side, where he had weakness and immobility. On the day of the fall, the resident needed to have a bowel movement but could not locate the call light despite feeling around the bed with his right arm. Unable to find the call light in time, the resident attempted to get out of bed independently to reach the bathroom, slid out of bed, and fell to the floor. Progress notes and incident documentation for the fall showed that the resident was found on the floor beside the bed after calling out for assistance, having had a bowel movement and attempting to get out of bed when he fell and hit his head. The resident was observed entangled in bedding and a PEG tube and was noted to be alert and oriented to baseline. The post-fall evaluation documented that the resident did not have the call light activated at the time of the fall. The resident’s fall care plan included an intervention to ensure the call light was within reach at all times. An LPN who was working that night reported hearing someone yelling, finding the resident on the floor, and confirming that the resident stated he had to use the bathroom and had a bowel movement in bed. The LPN also stated that the resident was able to use the call light appropriately when he had care requests.
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