Failure to Ensure Call Lights Accessible to Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure call lights were within reach for two residents with cognitive and physical impairments. For one resident with severe cognitive impairment, dementia, and multiple physical diagnoses, the call light was observed on the floor or hanging on the wall, out of reach, during multiple observations. The resident was unable to access the call light to request assistance and expressed a desire for help. The care plan for this resident addressed communication needs but did not include specific instructions regarding call light accessibility. For another resident with moderate cognitive impairment and a need for assistance with mobility and self-care, the call light was found on a chair next to the resident, not within reach, while the resident was in a recliner and unable to reposition herself. The resident stated she wanted help to lie down in bed. Staff acknowledged the call light was not accessible and assisted the resident upon entering the room. The care plan for this resident did include a directive to keep the call light within reach, but this was not followed during the observed incident. The Director of Nursing confirmed that all residents are expected to have call lights accessible.