Failure to Ensure Call Lights Within Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure that three residents had their call lights within reach, as required by their care plans and facility policy. Observations on the specified date revealed that one resident's call light was hanging over a nightstand approximately three feet away from his chair, making it inaccessible. This resident had severe cognitive impairment, was dependent on staff for most activities of daily living, and was care planned for falls with an intervention to keep the call light within reach. Due to his cognitive status, he was unable to communicate about the issue during the attempted interview. Another resident, who was cognitively intact but had diagnoses including paranoid schizophrenia, muscle weakness, and diabetes, was observed with his call light hanging between the wall and his bed, out of reach. He confirmed during the interview that he could not access the call light and would have to move his bed to reach it. The call light remained out of reach during a subsequent observation while the resident was asleep. His care plan also included an intervention to keep the call light within reach due to fall risk related to psychotropic medication use. A third resident, with moderate cognitive impairment, heart failure, and lack of coordination, was observed with her call light hanging towards the ground on the left side of her bed, also out of reach. She stated she could not reach it and was unaware of how long it had been inaccessible. Interviews with CNAs and facility leadership confirmed that it was the responsibility of all staff to ensure call lights were within reach and that failure to do so would prevent residents from calling for assistance. The facility's policy also required call lights to be within easy reach for residents in bed or confined to a chair.