Failure to Ensure Call Lights Within Reach for Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents who required substantial to maximal assistance with activities of daily living and had moderate cognitive impairment. Both residents had significant physical limitations, including muscle weakness, limited range of motion, and a history of falls, which increased their dependence on staff for assistance. Despite care plans specifying that call lights should be within reach to allow residents to request help, observations revealed that the call lights for both residents were clipped to bed sheets and positioned between the mattress and headboard or bed rail, making them inaccessible to the residents. During interviews, both residents confirmed they could not reach their call lights and were unsure how to summon help when needed. One resident reported being in pain and needing assistance with a bowel movement but was unable to call for help due to the call light's placement. Staff interviews corroborated that call lights were not within reach for these residents at the time of observation, and staff acknowledged the importance of call light accessibility for timely assistance. Further interviews with facility staff, including a CNA, LVN, Social Worker, Corporate Nurse, and DON, confirmed that call lights should always be within reach of residents unless otherwise care-planned for resident preference. The DON also noted that the facility did not have a specific policy addressing call light placement. The deficiency was identified through direct observation, resident and staff interviews, and review of care plans and assessments.