Failure to Maintain Call Lights and Essential Items Within Residents' Reach
Penalty
Summary
The facility failed to ensure that call lights and frequently used items were maintained within reach for three out of four residents observed. Observations and interviews revealed that one resident's call light and phone were often found on the floor, making them inaccessible when assistance was needed. Another resident was unable to reach her call light, which was attached to the top of the upper side rail, and a third resident's call light was left on a nightstand across the room, out of reach. These deficiencies were confirmed during observations with certified nurse assistants, who acknowledged the concerns related to call lights being out of reach. The affected residents had varying medical conditions, including chronic obstructive pulmonary disease, bilateral primary osteoarthritis of the first carpometacarpal joints, and cerebral infarction. Two of the residents were moderately cognitively impaired, while one was cognitively intact. Staff interviews, including with an LPN and the facility administrator, confirmed that call lights and frequently used items should always be within residents' reach, and acknowledged the issues observed during the survey.