Failure to Ensure Call Light Accessibility and Adequate Mattress Size
Penalty
Summary
Surveyors observed that multiple residents did not have their call lights within reach, limiting their ability to request assistance. For example, one resident was found in bed with the call light hanging behind the bed and inaccessible on several occasions throughout the day. The resident confirmed she could not reach the call light, and the CNA responsible acknowledged forgetting to attach it to the resident's pillow, as required by facility practice. The DON confirmed that staff are expected to ensure call lights are always accessible to residents. Other residents were also observed with call lights out of reach, including one sitting in a recliner with the call light tangled on the floor, and another lying in bed with the call light on the floor and not visible. Staff interviews confirmed that call lights should be within reach for safety and that all staff are responsible for ensuring accessibility. Residents affected had varying cognitive statuses, with some being cognitively intact and others having moderate to severe cognitive impairment. Additionally, one resident was repeatedly observed lying in bed with his feet hanging off the end of a mattress that was too short, with no support for his feet. The DON confirmed that the mattress was not the correct size and acknowledged the need for a mattress extender. The residents involved had medical histories including alcoholic polyneuropathy, repeated falls, schizophrenia, unspecified dementia, and other reduction deformities of the brain.