Failure to Ensure Resident Call Lights Were Accessible
Penalty
Summary
The facility failed to ensure that the call light system was accessible to all residents in their bedside, toilet, and bathing areas, as required for resident safety and communication. Observations revealed that three residents with severe cognitive impairment and significant mobility limitations did not have their call lights within reach. For one resident, the call light was found hanging between the bed and the wall, out of reach while the resident was sitting on the bed. Another resident's call light was placed on a roommate's bedside table, making it inaccessible while the resident was lying in bed. A third resident's call light was observed on the floor approximately 40 feet away from the bed, also out of reach. Interviews with the affected residents confirmed that the call lights were rarely or never within reach, and in some cases, residents had to go to great lengths, such as reaching under furniture, to access them. One resident stated that the call light was always hung straight to the floor and did not use it. The residents involved had diagnoses including severe cognitive impairment, mobility issues, and other complex medical conditions, making them particularly dependent on staff assistance and the ability to summon help when needed. Staff interviews, including those with the ADON, LVN, MA, and ADM, indicated that all were aware of the policy requiring call lights to be within residents' reach and acknowledged the importance of this practice for resident safety. Staff described that call lights should be checked during rounds and that all staff were responsible for ensuring accessibility. However, they also admitted that call lights were sometimes not placed back within reach after care activities, and some staff did not pay adequate attention to this requirement. The facility's policy on call lights and dignity was requested but not provided during the survey.