Failure to Ensure Call Lights Were Accessible and Functional for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach or functioning for three residents, as required by their care plans and facility policy. One resident with chronic obstructive pulmonary disease, acute kidney failure, and mild cognitive impairment was observed lying in bed with the call light placed on the far back corner of the nightstand, covered by a curtain and not within reach or sight. Another resident with spinal stenosis, heart failure, and a history of falls was observed sitting in a recliner with the call light placed on the footboard of the bed, hanging down between the mattress and footboard, also out of reach and sight. In both cases, the care plans specified that call lights should be kept within reach due to the residents' fall risks and physical limitations. An LPN confirmed that the call lights were not accessible to these residents at the time of observation. A third resident, who had diabetes with polyneuropathy, a recent amputation, and required assistance with multiple activities of daily living, was found to have a non-functioning call light. The resident reported that the call light had not worked for about a week and was given a bell to ring for help instead. Observations confirmed that the call light did not activate the indicator outside the door when pressed. The Director of Plant Operations later verified that the call light cord connected to the new system was not provided to the resident and was found lying on the floor out of reach. The facility's policy required staff to ensure call lights were plugged in and within reach, which was not followed in these instances.