Failure to Keep Call Lights Within Reach for Residents with Impairments
Penalty
Summary
The facility failed to ensure that call lights were kept within reach for two residents, both of whom had significant physical and cognitive impairments and were at risk for falls. In one instance, a resident with severe cognitive impairment, generalized muscle weakness, lower extremity impairments, and a history of falls was observed sitting in a wheelchair at the foot of her bed with her call light placed on the bed, out of her reach. Her care plan specifically required that the call light be kept within easy reach to allow her to request assistance, but this intervention was not followed. In another case, a resident with moderate cognitive impairment, severe vision loss (legal blindness), generalized muscle weakness, and upper and lower extremity impairments was observed in a wheelchair with the call light cord and button wrapped around the bed's side rail, behind him and not accessible. This resident was heard calling out for a nurse, indicating he could not use the call light to request help. Both residents had care plans and fall risk assessments that required staff to keep call lights within reach, and staff interviews confirmed that this standard was not met at the time of observation.