Failure to Ensure Call Lights Within Reach for High-Risk Residents
Penalty
Summary
The facility failed to ensure that the call light was within reach for two residents, both of whom were identified as high risk for falls and had significant cognitive and physical impairments. For one resident, who had muscle wasting, atrophy, impaired cognition, and was dependent on staff for all activities of daily living, the call light was observed hanging on the top of the bed board and not within the resident's reach while the resident was asleep. The care plan for this resident specifically required that the call light be within reach and that the resident be reminded to call for assistance with all transfers. The facility's Infection Prevention Nurse confirmed during observation that the call light was not accessible, and the DON stated that call lights should always be within reach for safety. For the second resident, who had anemia, muscle weakness, severely impaired cognition, used a wheelchair, and required substantial assistance for toilet transfers, the call light was not visible or within reach while the resident was in her wheelchair and verbally requesting assistance. The Infection Prevention Nurse had to retrieve and place the call light within reach during the observation. The DON confirmed that this resident was also at high risk for falls and reiterated the importance of call lights being accessible at all times. The facility's policy required that call lights be within easy reach of residents when in bed or in a chair.