Failure to Ensure Call Light Accessibility and Proper Staff Response
Penalty
Summary
Surveyors found that staff failed to ensure call devices were within reach for two residents and did not consistently inquire about residents' needs when responding to call lights. In one instance, a resident's call device was found behind the nightstand and tangled, making it inaccessible. A Licensed Practical Nurse acknowledged the device was not within reach and corrected its placement. A Certified Nursing Assistant admitted not checking the call light's placement during the last room visit. In another case, a staff member responded to a call light by informing a resident about lunch but did not ask what assistance was needed before turning off the call light and leaving the room. Both residents involved had significant medical histories and cognitive impairments. One resident had a history of falls, hypertension, osteoporosis, and a moderate cognitive impairment, with care plans specifying the need for the call light to be within reach. The other resident had severe dementia, poor vision, and required substantial assistance with self-care, with a care plan identifying high fall risk and the need for safety measures. Facility policies and job descriptions require call lights to be within reach and staff to inquire about residents' needs, but these procedures were not followed in the observed incidents.