Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents who were at risk for falls, incontinence, and other health concerns. Observations on the specified date revealed that the call lights for all three residents were found on the ground or under the bed, making them inaccessible. One resident, who was in a wheelchair, attempted to reach the call light on the ground but was unable to do so. The other two residents were observed in bed with their call lights similarly out of reach, and both declined to answer questions during the surveyor's visit. Each of the affected residents had significant medical histories, including dementia, unsteadiness, muscle weakness, incontinence, and a history of falls. Their care plans specifically required that call lights be kept within reach at all times due to their risk factors. Documentation showed that staff had checked on these residents earlier in the day, but the call lights were still not accessible at the time of observation. Staff interviews confirmed that they had been in-serviced on the importance of call light placement and were aware of the policy requiring call lights to be within reach whenever care was provided or when leaving a resident's room. Despite staff training and facility policies, the deficiency occurred because staff did not consistently ensure that call lights were accessible to residents. The facility's own policies and the Guardian Angel Program emphasized the importance of call light accessibility for resident safety and communication. However, the observations and interviews demonstrated a lapse in following these procedures, resulting in residents being unable to summon assistance when needed.