Failure to Ensure Call Lights Within Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for eight out of twelve residents reviewed for call light accessibility. Multiple observations documented that residents with significant mobility limitations, cognitive impairments, and fall risks did not have their call lights accessible. In several cases, call lights were found looped around the headboard, under blankets, or on the opposite side of the bed, making them unreachable for the residents. Family members and staff interviews confirmed that residents were unable to access their call lights without assistance, and in some cases, residents were unaware of the location of their call lights. Residents affected by this deficiency had various medical conditions, including recent joint replacements, heart failure, chronic obstructive pulmonary disease, diabetes, muscle weakness, Alzheimer's disease, and severe cognitive deficits. Care plans for these residents consistently included interventions instructing them to use the call light for assistance before transferring or getting out of bed. Despite these documented interventions, staff did not ensure that call lights were placed within reach, as observed during multiple surveyor visits and confirmed by staff and family interviews. Staff interviews revealed an expectation that call lights should be within reach of all residents, and the facility's own policy required staff to ensure call lights were accessible before leaving a resident's room. However, repeated observations showed that this policy was not consistently followed, resulting in residents being unable to summon assistance when needed. The deficiency was identified through direct observation, resident and family interviews, and review of care plans and facility policy.