Failure to Ensure Call Lights Accessible to Residents
Penalty
Summary
The facility failed to ensure that four residents had their call bell devices accessible and within reach while in their rooms, as required by facility policy. The policy specifies that call lights must be plugged in at all times and within easy reach of residents when they are in bed or confined to a chair. Multiple observations by the surveyor revealed that the call lights for these residents were consistently found on the floor or draped over the far side of nightstands, making them inaccessible to the residents. The residents involved had varying degrees of cognitive impairment and physical limitations, including histories of falls, dementia, pelvic fracture, chronic pain, and adult failure to thrive. Some residents were unable to locate their call lights or did not respond when asked about them, while others stated they could not find or reach their call lights. In several instances, the call lights were observed out of reach during multiple checks throughout the day, regardless of whether the residents were awake or asleep. Interviews with staff, including CNAs, nurses, the ADON, and the DON, confirmed that all residents should have access to their call lights, regardless of their ability to use them. Staff acknowledged that the call lights were not within reach and that this was not in accordance with facility policy. The deficiency was identified through repeated observations and staff interviews, which consistently demonstrated a lack of compliance with the requirement to keep call lights accessible to residents.