Failure to Ensure Call Lights Within Reach and Proper Resident Positioning
Penalty
Summary
Surveyors observed that the facility failed to ensure that call lights were within reach for multiple residents, as required by their individualized care plans. During a random tour, six residents were found with their call bells either on the floor, under the bed, draped over wall lights, or otherwise out of reach. These residents had documented care plans indicating self-care performance deficits, muscle weakness, cognitive deficits, dementia, deconditioning, and high risk for falls, with specific interventions requiring that call lights be kept within reach and residents encouraged to use them for assistance. In each case, the call bell was not accessible to the resident at the time of observation. Additionally, one resident was observed sitting in a semi-reclining wheelchair with legs bent and unsupported, despite having a reclining chair available in the room that would have provided proper leg support. This resident's call bell was also found out of reach. The care plans for these residents consistently included interventions to keep call lights accessible and to encourage their use, particularly due to their risk for falls and limited mobility. The observations demonstrated a failure to follow these care plan interventions, resulting in residents not having access to assistance when needed and not being positioned comfortably.