Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
A deficiency was identified when a resident's call light was repeatedly found out of reach, specifically on the floor, during multiple observations. The resident, who was in bed and awake during these times, expressed a need for assistance but was unable to locate the call light button. Instead, the resident resorted to calling out for staff verbally. Staff members, including a registered nurse and a certified nursing assistant, confirmed that the call light should have been within the resident's reach and acknowledged that it was found on the floor during their checks. The facility's policy and procedure on call light accessibility and timely response required that call lights be within reach of residents and secured as needed. Despite this policy, staff interviews revealed that the call light for this resident often fell to the floor, particularly because the resident moved frequently in bed. The call light was equipped with a clip intended to secure it to the bedsheet, but this was not consistently utilized, resulting in the call light being inaccessible to the resident on more than one occasion. Medical record review indicated that the resident had been admitted to the facility several weeks prior to the observations. During the deficiency events, the resident was in need of assistance, including pain management, but was unable to summon help using the call light due to its inaccessibility. Staff acknowledged the issue and confirmed that the call light should always be within the resident's reach, as per facility policy.
Plan Of Correction
1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 63 was affected by this deficient practice. Immediately, both RNA 1 and CNA 1 put the call light next to resident. DSD provided 1:1 education to RNA 1 and CNA 1 about call light placement and making sure call lights are within reach. On 7/25/2025 and 8/4/2025-8/8/2025, DON and DSD in-serviced all staff regarding call light placement and making sure they are within resident reach. In-serviced included frequent monitoring of call lights within resident reach for residents who have a tendency to push the call light away and making sure the nursing supervisor is made aware and the plan of care is updated. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. All residents were potentially affected by this deficient practice. On 7/24/2025, all department heads did a room rounds to check if any other resident was affected and found no other resident with issues. On 8/4/2025, the Administrator and Maintenance Director checked all call lights to make sure they have clips to keep call lights next to residents’ reach and no other issues were noted. 3. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: The Administrator and designee will oversee this process. Department heads and designee will do daily room rounds to check for call light placement and report to daily morning meetings for any non-compliance for 4 weeks. 4. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; Integrate QA Process: The Administrator will monitor the effectiveness of the process and any findings will be presented to the Monthly QA&A meeting. The Plan of Correction will be presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025 4. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; Integrate QA Process: The Administrator will monitor the effectiveness of the process and any findings will be presented to the Monthly QA&A meeting. The Plan of Correction will be presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025