Failure to Ensure Call Light Accessibility for Multiple Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible to multiple residents, as observed during staff and resident interviews, clinical record reviews, and direct observation. One resident with no cognitive impairment, a history of falls, and requiring moderate assistance for transfers was found with her call light out of reach on the bedside stand and her bed control on the floor. She confirmed she could not reach the call light and would have to yell for help if needed. Another resident, also with no memory impairment and a history of stroke and hemiplegia, was found calling out for assistance and rattling the bed rail because the call light was on the wall and out of reach. This resident was found incontinent of bowel and bladder and reported being unable to call for help due to the inaccessible call light. A facility-wide call light audit further revealed several instances where call lights were not accessible to residents in their rooms. Observations included call lights hanging on the wall, on the floor, or placed in drawers, all out of reach of residents who were in bed or in wheelchairs. In some cases, residents were unaware of the location of their call lights. The facility's policy requires that call lights be within easy reach of residents when they are in bed or confined to a chair, but this was not consistently followed.