Failure to Ensure Call Lights Were Within Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for four sampled residents, as required by its own policy and care plans. Observations and interviews revealed that residents with significant cognitive and physical impairments did not have access to their call lights, which are essential for requesting assistance. For example, one resident with severely impaired cognition and high fall risk was found unable to reach the call light, which was stuck behind the headboard. Nursing staff confirmed the call light was not accessible and acknowledged the importance of keeping it within reach. Another resident with hemiplegia and severely impaired cognition was observed unable to reach the touch call light, which was placed above the resident's non-functional side. Staff interviews confirmed that the call light should have been placed near the resident's dominant, functional hand. Similarly, a resident with a left hand contracture and severe cognitive impairment had the call light placed on the side of the contracted hand, making it inaccessible. Staff confirmed the resident could only use the right hand and that the call light should have been placed accordingly. A fourth resident, with moderate cognitive impairment and mobility issues, was found sitting in a wheelchair with the call light wedged behind the bed and out of reach. The resident stated they could not access the call light when not in bed and would have to yell for help. Staff interviews consistently indicated that call lights should always be within reach, and the facility's policy required staff to ensure accessibility with each interaction. The failure to follow these procedures was observed across all four cases.