Failure to Ensure Call Lights Within Reach for Dependent Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure call lights were within reach for two residents who required substantial or maximal assistance with activities of daily living. One resident, diagnosed with multiple sclerosis, arthritis, and malnutrition, was observed multiple times with the call light placed on the nightstand near the foot of the bed, out of reach, both while awake and asleep. Staff were seen leaving the room without repositioning the call light within the resident's reach, despite care plan interventions specifying this requirement. Another resident, with diagnoses including autonomic nervous system disorder, syncope, and urinary retention, and who utilized an indwelling urinary catheter, was also observed on several occasions with the call light on the floor, out of reach, whether in bed or in a wheelchair. Staff interviews confirmed the expectation that call lights should be within easy reach, and facility policy directed staff to ensure this for all residents. Despite these guidelines, repeated observations documented the call lights being inaccessible to the residents.