Failure to Maintain Accessible Call Light Leads to Resident Fall and Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents for one resident at risk for falls. The resident was admitted with a left humerus fracture, weakness, and pain, and an admission fall risk assessment identified the resident as being at risk for falls. The care plan noted a potential for falls due to a history of falls and a recent left shoulder fracture and included an intervention to ensure the resident’s call light was within reach. On the night prior to the fall, a CNA assisted the resident to the bathroom and then into a recliner. The CNA left the room call light secured to the bed, approximately four feet from the recliner and out of the resident’s reach, and did not place the resident’s wrist call light on the resident. The resident had intact cognition and was known to consistently use the call light and had not self-transferred previously during the stay. At approximately 6:00 AM, the resident self-transferred to the bathroom without assistance, resulting in an unwitnessed fall in the room. Staff became aware of the fall after a family member called the facility, having been texted by the resident that help was needed. When the RN assessed the resident, the resident was found on the floor with pain in the left arm, the room call light clipped to the bed and out of reach, and the wrist call light in the nightstand. Hospital evaluation following the fall revealed a worsened comminuted fracture of the left humerus, an acute to subacute L1 compression fracture, and a scalp hematoma, and the resident later underwent surgery for the left humerus fracture.
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