Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible to residents as required by their care plans and facility policy. Observations revealed that one resident was unable to locate the call light, which was found under the bed, and the resident was unaware of its location. This resident had a history of repeated falls, vascular dementia, and mobility impairments, and was care planned to have the call light within reach due to high fall risk. Another resident was observed with the call light on the floor, and a staff member acknowledged that the resident did not use the call light, so the door was kept open instead. A third resident was found sitting on the side of the bed with the call light wrapped around a bedside table out of reach, and was left waiting in urine for over an hour for assistance, expressing embarrassment and distress. Staff interviews confirmed that call lights were not always kept within reach, and that staffing shortages contributed to delays in providing assistance. Facility policies reviewed stated that call lights should be within easy reach of residents when in bed or confined to a chair, and that residents unable to perform activities of daily living independently should receive necessary assistance. Staff acknowledged the importance of call light accessibility for timely response to resident needs, including pain management and toileting. The failure to keep call lights within reach was observed to directly impact residents' ability to request help, resulting in delays in care and unmet needs.