Failure to Ensure Call Light Accessibility for Multiple Residents
Penalty
Summary
The facility failed to ensure that three residents had access to their call lights, as required by their care plans and facility policy. For one resident with Parkinsonism and a high fall risk, the call light was found wrapped up in a basket on the nightstand, approximately four feet away and out of reach. The resident confirmed he could not reach the call light, though he stated staff usually kept it within reach. A medication aide verified the call light was not accessible and acknowledged the importance of keeping it within reach. Another resident, who had diagnoses including dementia, Parkinsonism, and hemiplegia, was observed with his call light attached to the bed behind him, making it inaccessible while he was in his wheelchair. The resident was unaware of the call light's location and could not reach it. Later, the call light was observed draped over a roommate's nightstand and another call light was found on the floor, both out of reach. The administrator confirmed the call light should have been within the resident's reach. A third resident, with a traumatic brain injury and severe cognitive and communication deficits, was observed twice with his call light tucked inside a closed nightstand drawer, out of reach. Staff interviews confirmed the call light was not accessible and that all staff are responsible for ensuring call lights are within reach. Facility policy and recent in-service training emphasized the requirement for call lights to be accessible to residents at all times.