Failure to Ensure Call Light Accessibility and Prevent Elopement
Penalty
Summary
Facility staff failed to ensure that call lights were accessible to four residents, resulting in situations where residents could not summon assistance when needed. One resident with left-sided weakness from a stroke was unable to reach his call light, which was tied to the bed and out of reach, leading him to call for help by yelling. Another resident, who reported difficulty breathing, did not have a call light within reach and required the surveyor to activate the call button for staff assistance. A third resident reported falling because she could not call for help before getting up, despite signage reminding her to do so, as her call light was not accessible. A fourth resident, who was unable to verbalize his needs, had his call light taped to the wall and was not able to use it, with staff unaware of who had done this. Staff interviews revealed there was no facility policy related to call lights. The facility also failed to prevent elopement for one resident with a diagnosis of unspecified mild dementia with agitation, who was known to wander and had impaired safety awareness and judgment. This resident was observed wandering the hallways, attempting to exit the building, and entering other residents' rooms without supervision. The resident had previously eloped by removing a window and screen from his room and exiting the facility, and on another occasion was found outside near the parking area. Staff interviews confirmed that the resident was on 15-minute checks, but there were missing visual check records for several days and incomplete documentation on other days. Staff also stated that the resident's door should have been open for supervision, but it was found closed multiple times without explanation. Review of the resident's care plan indicated interventions such as frequent checks and 1:1 supervision for safety and elopement risk, but these were not consistently implemented or documented. The facility's elopement policy did not specify procedures to follow after an incident report was filed. These deficiencies in supervision and environmental safety placed residents at risk of falls, injuries, elopement, or negative outcomes if a medical crisis occurred and assistance could not be summoned.