Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for four residents, each with significant medical conditions and high risk for falls or limited mobility. In multiple instances, staff observations and interviews confirmed that call lights were either on the floor, tangled, or otherwise not accessible to the residents. For example, one resident with epileptic seizures, muscle weakness, and impaired decision-making had a call light on the floor, out of reach, during an observation with a CNA, who acknowledged the risk this posed. Another resident with schizoaffective disorder, diabetes, and upper extremity impairment had a pad call light placed on her lap, which staff confirmed was not within her reach due to her physical limitations. Additional observations revealed that a resident with seizures, psychosis, diabetes, and left upper extremity impairment repeatedly had a call light tangled or on the floor, making it inaccessible. Staff interviews confirmed awareness of the resident's inability to reach the call light and the importance of its placement. Similarly, a resident with epilepsy, Parkinson's disease, and left-sided hemiplegia was found with a call light dangling off the bed and out of reach. Staff entering the room failed to notice or correct the situation, and the resident was unable to access water or the call light, as confirmed in interviews with both the resident and staff. Facility policies and procedures reviewed during the survey consistently required that call lights be within reach of residents to ensure prompt assistance and safety. Despite these policies, staff did not consistently follow them, as evidenced by repeated observations and staff admissions. The Director of Nursing and other staff acknowledged the expectation and necessity for call lights to be accessible at all times, but the deficiency persisted across multiple residents and shifts.