Call Lights Not Accessible to Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights were available for use and within reach for three of five residents sampled. According to facility policy, call alert devices are to be placed within the resident's reach and staff are to answer call alerts promptly. For one resident with heart failure, dysphagia, and major depressive disorder, and another with parkinsonism, chronic pain, and anxiety, both were found lying in bed unable to locate or reach their call lights, which were observed on a nightstand behind and to the side of their beds. Both residents were dependent on staff for toileting, dressing, personal hygiene, and transfers, and their care plans specifically required that call lights be within reach. A CNA confirmed that the call lights were not accessible and admitted forgetting to return them to the residents' reach. A third resident, who had COPD, required assistance with personal care, had difficulty walking, and a history of falls, was also affected. This resident's care plan required the call light to be within reach and for staff to encourage its use. The resident's family member reported multiple instances of finding the call light on the floor, and noted that the resident would attempt to get up independently, resulting in frequent falls. The administrator confirmed that call lights should always be within reach and that it was not facility practice for them to be out of reach.