Call Lights Left Out of Reach for Dependent Residents
Penalty
Summary
Staff failed to ensure that two residents, both with physical impairments and unable to self-transfer, had access to their call lights. On separate occasions, one resident's call light was found on the floor out of reach while the resident was asleep in bed, and another resident's call light was pinned to a pillow on a recliner across from the bed, also out of reach. Both residents were unable to independently retrieve the call lights due to their physical and, in one case, cognitive limitations. Interviews with staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that facility expectations required call lights to be within residents' reach at all times, either pinned to the resident or their bed. The facility's Fall Management System policy emphasized providing appropriate equipment and interventions to ensure resident safety and prevent falls. However, the facility did not provide a specific policy related to the accommodation of needs as requested during the survey.