Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
A deficiency was identified when a resident was repeatedly observed without access to their call light while in bed. On multiple occasions, the call light was found behind the head of the bed on the floor or clipped to a bed sheet out of the resident's reach. The resident, who had moderately impaired cognition and required partial to moderate assistance with bed mobility and activities of daily living, was unable to reach the call light when asked. The resident reported relying on the call light to alert staff for assistance, but was unable to access it during the observations. Interviews with nursing staff, including an LPN and the Director of Nursing, confirmed that all staff were required to ensure call lights were within reach of residents. The resident's care plan specifically included an intervention to keep the call light in reach at all times due to a risk for falls related to poor safety awareness and the need for assistance with mobility. Despite this, staff failed to ensure the call light was accessible, as evidenced by repeated observations and staff acknowledgment of the requirement.