Failure to Ensure Accessible Call Bell System for Capable Residents
Penalty
Summary
The facility failed to ensure that residents who were physically capable of using the call bell system had call bells accessible and within reach. Observations on 04/28/2025 revealed that five residents were either lying in bed without a call bell available in the wall system or had the call bell placed behind the bed on the floor, making it inaccessible. Review of the facility's policy indicated that call lights should be kept within reach of residents, either clipped to sheets, tied to the side rail, or clipped to a bedside chair. Despite this policy, the call bells for these residents were not accessible as required. Record reviews showed that all five affected residents had no impairment of upper extremities, confirming their ability to use the call bell system. Interviews with facility staff, including an LPN, the program director, and the administrator, confirmed that these residents were physically able to use the call bell and that the call bells should have been accessible and within reach. The deficiency was identified through direct observation, record review, and staff interviews, all of which corroborated the lack of accessible call bells for these residents.