Failure to Ensure Resident Call Lights Were Accessible
Penalty
Summary
The facility failed to ensure that call lights were readily accessible to residents in multiple observed instances. For one resident with muscle weakness and a left below-knee amputation, who was dependent on staff for most activities of daily living and had moderate cognitive impairment, the call light cord was repeatedly observed to be out of reach. The cord was draped across the overbed light fixture and dangled down the wall, making it inaccessible from the resident's wheelchair on the left side of the bed. This was observed on several occasions over multiple days. The resident confirmed they could not reach the call light and would have to wait for staff to pass by and call out for help if needed. A registered nurse acknowledged that the call light should have been within the resident's reach. Another resident, admitted with a history of syncope, falls, and functional impairments, also had their call light placed out of reach on multiple occasions. The call light was either pinned to the wall cord or found on the floor behind the bed, making it inaccessible from the resident's position. This resident had a documented history of falls both prior to and after admission. Staff observed the call light on the floor and acknowledged it should have been left within the resident's reach. The facility administrator stated that staff were expected to leave call lights accessible to residents.