Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible to six out of fifteen residents, as required by their own policy. Multiple residents were observed without call lights within reach, with some call lights either wrapped around outlet boxes, behind headboards, or on the floor. In one case, a resident had been using a bell for about a year to call for assistance because the call light was not functional and not within reach. The bell was not effective in alerting staff, as it could barely be heard at the nurse's station. Another resident was found with a call light cord behind the headboard, out of reach, and no mechanism was in place to prevent the cord from falling out of reach. Several residents expressed frustration or resorted to yelling for help due to the inaccessibility of their call lights. Staff interviews confirmed that some residents had been without accessible or functional call lights for extended periods, and in one instance, a resident had been using an alternative signaling device for about a year. Observations also revealed that some residents were unsure of how to use the call light system or mistook other devices, such as bed or TV remotes, for call lights. The facility's policy requires staff to ensure call lights are within reach and secured as needed, but this was not consistently followed, resulting in residents being unable to reliably summon assistance when needed.
Plan Of Correction
F558 – Reasonable Accommodations of Needs/Preferences Element #1: The Maintenance Director and designee conducted rounds to ensure that call lights were accessible to all cited residents (R4, R7, R23, R26, R46, R134). Faulty equipment was replaced or repaired, cords were secured properly, and staff were directed to check accessibility at each point of care. Element #2: A facility-wide sweep was conducted by the Maintenance Director and designee to assess call light accessibility for all residents. Maintenance documented and addressed any additional concerns observed. Element #3: The Administrator reviewed the Call Light Accessibility policy and updated as necessary. Community staff were re-educated regarding call light accessibility, function, and response. Element #4: The Director of Nursing and/or designee will conduct random weekly audits of 10 residents for 12 weeks to ensure call lights are within reach and functioning appropriately. Any concerns will be immediately corrected. Results of the audits will be brought to the QAPI Committee monthly for review. The QAPI Committee will be responsible to determine changes to the auditing process. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025