Failure to Ensure Call Lights Were Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, as observed and confirmed through interviews and record reviews. One resident with a history of hemiplegia following a stroke, vascular dementia, and moderate cognitive deficit was found sitting in bed with the call light dangling on the left side, wedged between the bed rail and mattress. The resident confirmed the call light was on his side of the bed. Another resident, who had a history of stroke, above-the-knee amputation, and intact cognition, was observed sitting up in bed with the call light on the floor at the head of the bed near the wall. This resident was unaware of the call light's location. Staff interviews revealed that both nursing and administrative staff acknowledged the importance of keeping call lights within residents' reach for safety and emergency purposes. However, the licensed vocational nurse was not aware that the call lights for these two residents were out of reach. The facility's policy stated that call lights should be placed within easy reach of residents, but this was not followed in these instances.