Failure to Ensure Call Light Accessibility for Multiple Residents
Penalty
Summary
Surveyors found that the facility failed to ensure call light buttons were placed within reach for four out of six sampled residents. During inspection, call light buttons were observed to be inaccessible: one was behind a pillow at the head of a bed, another was on the floor, and two were on beds but out of reach. Interviews with residents confirmed they could not access their call lights, and staff interviews revealed that in some cases, the call lights were not placed within reach after care was provided or were not provided due to assumptions about residents' abilities to use them. The facility's policy requires call lights to be placed within reach before staff leave the room. The residents affected had significant medical conditions, including diabetes, heart failure, kidney failure, epilepsy, osteoarthritis, hypertension, encephalopathy, schizophrenia, dementia, dysphasia, and physical limitations such as a contracted hand. Some had a history of falls and required assistance with mobility and transfers. Documentation reviewed included admission records, MDS assessments, care plans, and nurse notes, which indicated the need for call lights to be accessible as part of fall prevention and to allow residents to communicate their needs.