Failure to Ensure Call Lights Within Reach for Dependent Residents
Penalty
Summary
The facility failed to accommodate the needs and preferences of two residents by not ensuring that their call lights were within reach, as required by facility policy and care plans. For one resident with encephalopathy, bone density disorder, and atherosclerotic heart disease, who was assessed as high risk for falls and dependent on staff for most activities of daily living, the call light was observed hanging six inches from the floor and not accessible while the resident was in bed. Both a licensed vocational nurse and a registered nurse confirmed that the call light was not within reach and acknowledged that the resident could not use it to request assistance when needed. Similarly, another resident with dementia, Parkinson's disease, osteoarthritis, a history of fractures, and severely impaired cognition was found lying in bed with the call light hanging on the side of the bed, out of reach. The resident called for help, and a certified nursing assistant confirmed that the call light was not accessible to the resident, who otherwise knew how to use it. The facility's policies and care plans for both residents specifically required that call lights be kept within reach to address their high risk for falls and visual deficits. Interviews with staff, including the Director of Nursing, confirmed the expectation that call lights should always be within reach as per policy.