Failure to Maintain Accessible Call Lights for Fall-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement fall-risk care plan interventions by not ensuring that call lights were within reach for two residents identified as at risk for falls. Resident 1, who had diagnoses including a vertebral compression fracture and repeated falls, was observed standing from her bed, using a walker, and ambulating to the bathroom unassisted, appearing unsteady. A CNA stated that this resident required staff assistance to the bathroom due to fall risk and was supposed to call for help. When asked for the call light, the resident, who was hard of hearing, did not understand, and the CNA found the call light on the floor behind a nightstand that was not close to the bed. The CNA then attached the call light to the bed and instructed the resident on its use. Resident 1’s care plan for fall risk included an intervention to ensure the call light was within reach and to encourage the resident to use it for assistance as needed. Resident 2, with diagnoses including seizures and benign prostatic hyperplasia with lower urinary tract symptoms, was also identified as a fall risk with a weak right side. During observation, this resident was lying in bed asleep, and a CNA reported the resident had not called that day. When asked about the call light, the CNA located it on the floor, then attached it to the resident’s pillow, acknowledging it should not have been on the floor and should be reachable. The CNA admitted that during the last round, she did not check whether the call light was within reach. Resident 2 had a prior unwitnessed fall while self-transferring from bed to wheelchair, and the care plan documented a risk for injury due to a fall with a goal of no further falls. Facility staff, including a LVN and the DON, stated that call lights should always be within arm’s reach of residents, consistent with facility policies on the call system and fall risk management, which require providing residents a means to call staff and identifying interventions to prevent falls.
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