Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for five residents who were assessed or care planned for their use. Resident #294, a female with Alzheimer's and other health issues, was observed multiple times with her call light out of reach, despite her care plan specifying the need for an accessible call light to reduce fall risk. Similarly, Resident #32, a male with Alzheimer's and other conditions, was repeatedly observed with his call light out of reach, contrary to his care plan that required personal items and the call light to be within reach. Resident #70, a female with a history of falls and severe cognitive impairment, had no safety interventions involving the call light in her care plan, and her call light was consistently out of reach. Resident #14, a female with dementia and other health issues, was unable to reach her call light, which was wrapped around the bed rail. Resident #9, a female with dementia and anxiety, was observed with her call light out of reach and was unable to locate it. The facility's policy required staff to ensure call lights were within reach during each interaction, but this was not adhered to, as evidenced by the observations and interviews conducted.