Call Light System Inaccessibility for Multiple Residents
Penalty
Summary
The facility failed to ensure that the call light system was accessible to three residents, as observed during multiple room visits and confirmed through staff interviews and record reviews. In one instance, a resident with dementia, dysphagia, and type 2 diabetes was found unable to reach the call light, which was wrapped around the bed rail and nearly touching the floor. The resident attempted but was unable to access it, and a Licensed Vocational Nurse confirmed its inaccessibility. Another resident with mobility issues, cognitive communication deficit, and a history of falls was found with the call light placed on top of the headwall light fixture, out of reach. The resident was unaware of the call light's location, and a Certified Nursing Assistant confirmed it was not within reach. A third resident with a history of right femoral neck fracture had the call light under the bed, also out of reach, and did not know its location. This was confirmed by a Licensed Vocational Nurse. A review of the facility's policy and procedure on the call system indicated that residents should be able to call for staff assistance from their rooms and toileting/bathing facilities. During interviews, the Director of Nursing and Assistant Administrator acknowledged that the policy was not followed in these cases and confirmed that the call lights were not accessible to the residents as required.