Failure to Ensure Accessible Call Light System for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with significant mobility impairments and a history of falls did not have access to a functioning call light system while in her room. The resident, who was dependent on staff for transfers, toileting, and other activities of daily living, was observed sitting in her wheelchair with the call light cord wrapped around the bedside rail and out of reach. Despite multiple staff entries into the room for various care activities, including meal delivery and blood draws, the call light remained inaccessible to the resident. The resident herself expressed the need to have the call light within reach to request assistance for toileting needs. Staff interviews confirmed that ensuring call lights are within reach is considered important for resident safety and fall prevention. However, both the CNA and LPN who interacted with the resident during the observed period did not notice or address the inaccessibility of the call light. The facility's policy requires that call lights be positioned within reach of residents, but this was not followed in this instance, resulting in the resident being unable to call for assistance when needed.