Failure to Ensure Call Lights Within Reach for Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents who were unable to self-transfer or had cognitive impairments. Observations revealed that one resident, who was unable to self-transfer, was found lying in bed with the call light placed on an over-the-bed table that was pushed away and out of reach. Another resident, who was cognitively impaired and unable to transfer herself, was observed asleep with her call bell on a bedside table that was not accessible, and her urinary catheter drainage bag was on the floor. A third resident, also unable to transfer himself, was found in bed with no call bell present. Staff interviews confirmed that call bells were expected to be within reach of all residents, and that staff were conducting frequent rounds due to a malfunctioning call light system. Despite these expectations, the facility did not provide a policy specific to call light accommodations, and multiple instances were documented where residents did not have access to their call lights, leaving them unable to call for assistance.