Failure to Ensure Call Light Accessibility and Provide Oral Care
Penalty
Summary
Surveyors identified that staff failed to ensure call lights were placed within reach for two residents and failed to provide oral care for one resident. For one resident with muscle weakness and hypertension, documentation showed the resident required significant assistance with activities of daily living (ADLs), including being dependent for toileting, lower body dressing, and transfers. The care plan specified that the call light should be placed within reach. During observation and interview, the resident reported being unable to see or reach the call light, expressing frustration at not being able to contact staff when needed. A CNA confirmed the call light was not accessible due to the resident's contracture and position in bed, acknowledging that this was not in accordance with the care plan and facility policy. The same resident also reported not having received oral care and lacking a toothbrush or toothpaste. The CNA stated that oral care had not been provided that day, despite the resident having already eaten two meals, and acknowledged that oral care should be performed after each meal. The CNA attributed the missed care to the resident's recent room transfer. A second resident, with hemiplegia and hypertension, was also found to have the call light out of reach, as it was hanging off the bed. This resident was dependent on staff for all ADLs and unable to use the call light unless it was placed next to them. An LVN confirmed the call light was not accessible and stated it should always be within reach. Facility policies reviewed by surveyors required staff to ensure call lights are within reach to provide prompt assistance and to support residents with ADLs, including personal and oral hygiene.