Failure to Ensure Call Lights Were Accessible for Residents at Risk
Penalty
Summary
The facility failed to ensure that call lights were within reach and accessible for two residents who required assistance with activities of daily living and were identified as fall risks. For one resident with severe cognitive impairment and a history of stroke and muscle wasting, the call light was observed clipped to a power cord at the foot of the bed, out of the resident's reach. The resident confirmed she could not access the call light in its current position. Her care plan specifically included the intervention of a reachable call light due to her fall risk. For another resident with moderate cognitive impairment, dementia, cancer, muscle weakness, and a history of falls, the call light was found on the floor under the bed, making it inaccessible. The resident stated that the call light was not always within reach and sometimes could not be found when needed. Staff interviews confirmed that call lights are expected to be within reach at all times, and both the CNA and LVN acknowledged the importance of this practice. The administrator also stated that it was his expectation that staff ensure call lights are accessible before leaving a resident's room.