Failure to Ensure Call Light Accessibility for Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for four residents who were reviewed for care needs. Multiple observations over several days showed that these residents, all of whom had severely impaired cognition and were totally dependent on staff for activities of daily living, did not have access to their call lights while in bed. Specifically, call lights were found on the floor, looped over the call box or vent cart, or hanging below the bed frame, making them inaccessible to the residents. The residents involved had significant medical conditions, including renal failure, diabetes, malnutrition, respiratory failure, and stroke. Facility policy required that call lights be accessible at each resident's bedside and that special accommodations be provided as needed, but these requirements were not met for the residents observed. The deficiency was identified through direct observation, interviews, and record review.