Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call lights for two residents were within reach, which is a critical component for residents to communicate their needs to the nursing staff. Resident 36, who was admitted with chronic obstructive pulmonary disease, hemiplegia, and muscle weakness, was observed with the call light on the floor behind the bed, out of reach. This was confirmed by a Certified Nursing Assistant (CNA) who acknowledged the protocol to keep the call light within reach to prevent falls and ensure timely assistance. The Registered Nurse (RN) also confirmed that the call light should be near the resident to avoid delays in service and care. Similarly, Resident 224, who had difficulty walking, muscle weakness, asthma, and congestive heart failure, was found with the call light device behind the bed on the floor, not within reach. The CNA and Licensed Vocational Nurse (LVN) both stated that the call light should be accessible to the resident for safety and to alert staff in emergencies. The Director of Nursing (DON) reiterated the importance of having the call light within reach to meet the resident's needs promptly. The facility's policy and procedure on the call system also indicated that call cords should be placed within the resident's reach to enable prompt communication with nursing staff.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/4/25, Certified Nursing Assistant (CNA) 3 removed the call light from the floor and placed it within reach of resident 36. On 3/4/25, Certified Nursing Assistant (CNA) 5 removed the call light from behind resident 224's bed and placed it within reach of resident 224. How the facility will identify other residents, having the potential to be affected by the same deficient practice, and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/4/25, Department Managers, including but not limited to the Administrator, Director of Nursing, Director of Staff Development (DSD), Social Services Director, Activities Director, Case Manager, Admissions Coordinator, Infection Preventionist, Minimum Data Set (MDS) Coordinator and Assistant, and Quality Assurance (QA) Nurse conducted visual rounds to ensure no other resident call light was not within reach. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/13/25, the Director of Nursing and Director of Staff Development in-serviced facility staff, including but not limited to Certified Nursing Assistants, Licensed Vocational Nurses, and Registered Nurses, and Department Managers on the facility's policy and procedure titled "Communication-Call System" with emphasis on the facility providing a call system to enable residents to alert the nursing staff from their beds and toileting/bathing facilities and promptly communicate their needs. The in-service also included placing the call cords within the residents' reach. Department Managers, including but not limited to the DSD, Social Services Director and Assistant, Activities Director, Case Manager, Admissions Coordinator, Infection Preventionist, MDS Coordinator and Assistant, and QA Nurse, will conduct room rounds daily for 5 days, weekly for 2 weeks, and monthly thereafter to ensure residents' call lights are in reach. How the facility will identify other residents, having the potential to be affected by the same deficient practice, and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/4/25, Department Managers, including but not limited to the Administrator, Director of Nursing, Director of Staff Development (DSD), Social Services Director, Activities Director, Case Manager, Admissions Coordinator, Infection Preventionist, Minimum Data Set (MDS) Coordinator and Assistant, and Quality Assurance (QA) Nurse conducted visual rounds to ensure no other resident call light was not within reach. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/13/25, the Director of Nursing and Director of Staff Development in-serviced facility staff, including but not limited to Certified Nursing Assistants, Licensed Vocational Nurses, and Registered Nurses, and Department Managers on the facility's policy and procedure titled "Communication-Call System" with emphasis on the facility providing a call system to enable residents to alert the nursing staff from their beds and toileting/bathing facilities and promptly communicate their needs. The in-service also included placing the call cords within the residents' reach. Department Managers, including but not limited to the DSD, Social Services Director and Assistant, Activities Director, Case Manager, Admissions Coordinator, Infection Preventionist, MDS Coordinator and Assistant, and QA Nurse, will conduct room rounds daily for 5 days, weekly for 2 weeks, and monthly thereafter to ensure residents' call lights are in reach. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will review the Department Manager room rounds and will report to the Quality Assurance and Improvement Committee during its monthly meeting the status of the compliance for call lights being in reach for three months or until compliance is met.