Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
Facility staff failed to provide appropriate access to the call light for one resident, despite facility policy and the resident's care plan requiring the call light to be within reach. The resident, who was cognitively intact and had diagnoses including abnormalities of gait, mobility issues, and weakness, was observed multiple times lying in bed with the call light hanging on the wall out of reach. The resident was alone in the room and unable to access the call light to request staff assistance. Interviews confirmed that the resident relied on the call light for help and was unable to locate or reach it during the surveyor's observations. Staff interviews, including with a CNA and the DON, confirmed that the expectation was for call lights to be within reach of all residents after care and whenever staff entered or exited the room. Despite these policies and expectations, the call light remained out of reach for the resident during several observations, and staff failed to ensure its proper placement. The resident's care plan specifically identified the need for the call light to be within reach due to fall risk, but this intervention was not followed.