Call Lights Not Accessible to Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach and easily accessible for two residents who required significant assistance with activities of daily living and had severely impaired cognition. For one resident with a history of falls, dementia, and limited mobility, the call light was observed on the floor out of reach while the resident was in bed. This was confirmed by a CNA, who acknowledged that the call light should have been placed next to the resident to allow her to call for help when needed. The resident's care plan specifically included an intervention to keep the call light within reach to provide a safe environment. For another resident with muscle weakness, upper mobility impairment, and a history of subarachnoid hemorrhage and encephalopathy, the touch pad call light was observed on the bed, out of reach, while the resident was lying in a geri-chair. The resident was seen attempting to reach the call light but was unable to do so. A CNA confirmed that the call light was not accessible and stated that the resident would not be able to call for assistance in an emergency. The care plan for this resident also required the call light to be within reach and answered promptly. Interviews with nursing staff and the DON confirmed that call lights should always be placed within reach of residents, as outlined in the facility's policy and procedures. The observations and staff interviews demonstrated that the facility did not follow its own policy, resulting in the call lights being inaccessible to residents who were dependent on staff for care and unable to independently summon assistance.