Failure to Ensure Call Lights Accessible to Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for five out of six residents reviewed for accommodation of needs. Multiple observations showed that residents were either lying in bed crying or sleeping, with their call lights found hanging out of reach or on the floor, sometimes tangled with other cords. Staff, including an LPN and an RN, entered and exited a resident's room without ensuring the call light was accessible. Despite care being provided by CNAs in several rooms, the call lights for these residents remained inaccessible throughout the observed period. The residents affected had significant medical conditions, including encephalopathy, vascular dementia, quadriplegia, Alzheimer's disease, and were at risk for falls. Their care plans and assessments indicated varying levels of cognitive impairment and dependence on staff for activities of daily living, with specific instructions for call lights to be within reach or placed in a particular position. Interviews with nursing staff and the DON confirmed that ensuring call lights are accessible is a shared responsibility among the nursing team, and that staff had been previously educated on this requirement.
Plan Of Correction
F 558 ELEMENT 1 It is the practice of the facility to provide reasonable accommodation of resident needs and preferences to include but not limited to ensuring call lights are within reach for the residents. R605, R606, R607, R608, and R609 call light were relocated to ensure they were within reach before the end of the survey. ELEMENT 2 Residents that currently reside in the facility have the potential to be affected by this cited practice. Residents have been reviewed to ensure call lights are within reach. Any deficiencies have been immediately corrected. ELEMENT 3 The Interdisciplinary Team reviewed the Call Light policy and deemed it appropriate. Staff have been educated on the Call Light policy with emphasis on ensuring the residents' call lights are within reach. ELEMENT 4 The DON/designee will complete random audits on 5 residents a week for 4 weeks, then 5 residents a month for 2 months to ensure call lights are within reach. Any deficient practice will be corrected/updated immediately. The results will also be taken to the Quality Assurance and performance review meeting. The Administrator and/or designee is responsible for compliance. Compliance Date: 5/8/25