Failure to Ensure Call Lights Were Accessible as Care Planned
Penalty
Summary
The facility failed to implement person-centered care plans for two residents by not ensuring their call lights were within reach, as required by their individualized care plans. For one resident with hemiplegia, vascular dementia, and a history of falls, the care plan specified that the call light should be in reach to address fall risk. On observation, the call light was found wedged between the bed rail and mattress, not accessible to the resident. The resident confirmed the call light was on his side of the bed but did not indicate it was within easy reach. For another resident with a history of stroke, epilepsy, diabetes, and an above-the-knee amputation, the care plan also required the call light to be in reach due to fall risk. Observation revealed the call light was on the floor near the wall, and the resident was unaware of its location. Interviews with nursing staff, including an RN and an LVN, confirmed the importance of keeping call lights within reach for resident safety and acknowledged that the care plan should be followed. The Director of Nursing also stated that the care plan should be adhered to for patient-centered care and that call lights should always be accessible to prevent falls or ensure help in emergencies. The facility's policy emphasized that care plans are to be used as guides to identify risks and direct care needs, but in these cases, the interventions were not implemented as documented.