Call Lights Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, each with significant medical and cognitive needs. For one resident with a history of subdural hemorrhage, atrial fibrillation, and dementia, the call light was observed hanging under the bed and out of reach while the resident was in bed with bilateral siderails up. The resident confirmed she could not reach the call light, and the attending LVN acknowledged the call light was not positioned within reach. Another resident, admitted with hemiplegia, hemiparesis, ataxia, and dysphagia, was found lying in bed with the call light dangling and out of reach. The resident attempted to locate the call light but was unable to find it and stated that she sometimes had to yell for help. A CNA confirmed the call light was not accessible and repositioned it within the resident's reach, stating it should always be accessible. A third resident, with a history of falls, bradycardia, and major depressive disorder, was observed sitting on the bed with the call light on the floor and out of reach. The resident stated that staff had changed his beddings and forgot to return the call light to an accessible position. The ADON confirmed the call light was not within reach and repositioned it. Facility policy and staff interviews confirmed that call lights are required to be accessible to residents at all times.