Deficiency: Inaccessible Resident Call Light System
Penalty
Summary
Surveyors identified a deficiency related to the accessibility of the resident call light system for two residents. Both residents were observed lying in bed with their call light buttons on the floor, out of their reach. Interviews with the residents revealed that they were unaware of the location of their call light buttons and could not access them when needed. Certified Nurse Assistant (CNA) 3 confirmed during interviews that the call light buttons were not within reach and acknowledged that they should have been accessible to the residents. Resident 85 had a history of dementia with severely impaired cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. This resident was dependent on staff for most activities of daily living, including transfers and hygiene. Resident 39 also had severely impaired cognition, with diagnoses including metabolic encephalopathy, schizophrenia, and depression. This resident was similarly dependent on staff for toileting, bathing, dressing, and mobility. Both residents' care plans and the facility's policy required that call lights be within reach and accessible at all times. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed the expectation that call light buttons should be placed within reach of residents. The facility's policy also stated that staff are responsible for ensuring the call light is accessible to residents while in bed or other sleeping accommodations. The failure to ensure the call light system was within reach for these two residents constituted a deficiency under federal regulations.
Plan Of Correction
F919 Resident Call System How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) On 04/07/2025 CNA 3 moved Resident #85 and Resident #39's call light within reach. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) On 04/08/2025 DSD and/or designee completed an audit ensuring that no further residents had call light out of reach. There were no other areas identified with the same deficient practice. All other rooms were observed to have call lights within reach. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) An in-service was initiated by facility DSD on 04/10/2025 to licensed nurses and CNAs regarding the importance of keeping the call light within resident's reach. d) Department Managers will conduct random audits of call lights during their facility guardian angel rounds to ensure they are within resident's reach. All issues identified will be corrected immediately and brought forth to the five day a week department manager meeting for review and resolution. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system: e) Department Managers will conduct random audits of call lights during their facility guardian angel rounds to ensure they are within resident's reach. All issues identified will be corrected immediately and brought forth to the five day a week department manager meeting for review and resolution. Administrator and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. 04/10/2025