Failure to Ensure Call Light Accessibility for Multiple Residents
Penalty
Summary
The facility failed to ensure that the call light system was within reach for three out of eight sampled residents, as required by their care plans and facility policy. For one resident with aphasia, dysphagia, and right-sided hemiplegia, observations revealed the call light was placed above the resident's head and not accessible to the resident's functional left hand. The resident was unable to locate or use the call light, and the assigned LVN confirmed it was not within reach, acknowledging that this prevented the resident from requesting assistance. Another resident, who had moderate cognitive impairment and required maximal assistance for mobility, was observed unable to reach the call light despite attempts to do so. The LVN present confirmed the call light was not within reach and emphasized the importance of accessibility for residents to request help. The resident's care plans specifically required the call light to be functional and reachable due to the resident's communication and fall risk needs. A third resident, with a history of anxiety disorder, muscle weakness, and high fall risk, was observed sitting in a wheelchair with the call light placed on the opposite side of the bed, out of reach. The resident stated an inability to access the call light when needed. The LVN and DON both confirmed that facility policy mandates call lights be within reach at all times, especially for residents at risk of falls or emergencies. Review of the facility's policy and procedures further supported the requirement for call lights to be accessible to all residents.