Failure to Ensure Call Lights Within Reach and Wheelchair Maintenance
Penalty
Summary
The facility failed to ensure that call lights were within reach for six out of thirteen residents reviewed, as required by their own Call Light/Bell policy. Observations revealed that call bells for several residents were either hanging on the wall, on the floor, or off the bed, making them inaccessible. These residents had varying degrees of cognitive impairment and physical limitations, including severe dementia, muscle weakness, hemiplegia, and unsteadiness on their feet. The policy states that the call device should be placed within the resident's reach before staff leave the room, but this was not consistently followed. Additionally, the facility failed to maintain a resident's wheelchair in good repair, as one resident was observed with wheelchair arms that were tattered, peeling, and worn. Interviews with the DON and Administrator confirmed that call bells should always be within reach of residents, indicating awareness of the policy. The deficiencies were identified through direct observation and review of medical records, which documented the residents' medical conditions and cognitive status at the time of the incidents.