Failure to Ensure Call Light Accessibility and Prompt Response
Penalty
Summary
The facility failed to ensure that patient call lights were accessible and answered promptly for two patients. For one patient with severe cognitive impairment, muscle weakness, and a history of traumatic brain injury, the call light was observed on the floor under the headboard, out of the patient's reach while the patient was lying in bed. This was confirmed by a registered nurse, who acknowledged that the call light was unreachable and that this could delay the patient's care needs. Facility policy requires that call lights be within reach and accessible to patients at all times. For another patient with a history of falls, reduced mobility, and a recent femur fracture, the call light was activated while the patient needed assistance with toileting. A certified nursing assistant walked past the room, saw the lit call light, but did not respond because the patient was not assigned to her that day. The CNA later confirmed she should have checked on the patient regardless of assignment. Facility policy states that any staff member who sees or hears an activated call light is responsible for responding. These failures had the potential to delay the provision of services and result in unmet patient needs.
Plan Of Correction
Measures that will be put into place to ensure that this deficiency does not recur. Beginning 3/11/2025, DSD initiated in-servicing for CNA and licensed nursing staff regarding ensuring call lights are in place and in reach of patients as well as ensuring that call lights are not passed in the hallway without answering. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur. Beginning 3/11/2025, DSDs will make weekly rounds of all patient rooms to ensure call lights are in place and within reach as well as that staff is not walking past call lights that are engaged in the hallways. These rounds will continue for 1 month or until substantial compliance is obtained. Any ongoing noncompliance will be reported by DSD at the monthly QA meeting. Date of corrective action would be completed: 04/03/25 C1115