Call Light Accessibility Not Maintained for Resident
Penalty
Summary
A deficiency was identified when a resident, who had been readmitted with diagnoses including epilepsy and osteoporosis, was observed in bed with their call light out of reach. The call light wire was found behind a pillow and the device itself was touching the floor, making it inaccessible to the resident. The resident's medical records indicated fluctuating capacity to understand and make decisions, but their most recent assessment showed intact cognition and a need for substantial to maximal assistance with upper body dressing. During an interview, an LVN confirmed that the call light should not be under the pillow or on the ground, as the resident needed it close by to request assistance. The DON also stated that the call light should be within reach to ensure the resident could call for help if needed. Review of the facility's policy confirmed that call lights are to be accessible to residents when in bed. The failure to ensure the call light was within reach constituted a lack of reasonable accommodation for the resident's needs.
Plan Of Correction
F558: REASONABLE ACCOMMODATIONS/ NEEDS/ PREFERENCE CORRECTIVE ACTION Resident 20's call light is within reach on 3/4/2025 immediately after staff was notified. OTHER RESIDENTS AFFECTED IDENTIFICATION All active residents including residents newly admitted residents have the potential to be affected by this deficient practice. The facility conducted an interview of 7 alert, oriented residents on 3/21/25 to 3/28/25. All 7 residents indicated their call light is within reach, and their needs were met timely by the facility staff. No other residents were affected by the deficient practice at this time. MEASURES AND SYSTEMIC CHANGES In-service was conducted by DON/Designee to staff between 3/7/2025 to 3/28/2025 regarding improvement of call light management to enhance quality of life, care tasks, toileting, and promote dignity and respect. Department Managers shall perform room rounds daily from Monday to Friday, RN Supervisor/Designee on Saturday and Sunday. These rounds will ensure that the call light is within reach of the resident when on bed and sitting in the wheelchair in his room. Any negative findings from the room rounds will be corrected immediately and be reported during stand-up meetings. MONITORING PERFORMANCE The Administrator or his designee and the DSD will conduct quality room rounds weekly to ensure that the call light is within reach of the resident when on bed and sitting in the wheelchair in his room. Any negative findings from the room rounds will be corrected immediately and will be presented to the QA Committee monthly for the first three months for further evaluation and recommendations; quarterly thereafter if no negative trends are found. This correction will be monitored by the facility administrator/designee for continuous compliance and will be presented to the Monthly QAA Committee for the first three months for further evaluation and recommendations; quarterly thereafter if no negative trends are found. 3/28/2025