Failure to Ensure Call Bells Within Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure that call bells were within reach for three out of six residents observed during the survey. For one resident with Alzheimer's disease, dementia, and severely impaired cognition, the call bell was not present on the correct side of the bed and was instead plugged in on the opposite side, hanging on the floor and out of sight. A Licensed Practical Nurse confirmed that the resident, who was able to activate a call bell, did not have one within reach at the time of observation. Another resident, admitted with multiple diagnoses including traumatic brain injury, muscle weakness, and cognitive impairment, was found in bed without the call bell in reach; it was draped across a bedside table drawer, out of the resident's reach. Certified Nurse Aides verified that the resident could activate the call bell if it were accessible, but it was not positioned appropriately. A third resident, with a history of cerebral infarction, dementia, and legal blindness, was observed sitting in a recliner with the call light activated but lying on the floor, detached from the wall and out of reach. Staff confirmed the call light was not accessible to the resident. Review of facility policy indicated that call lights are to be placed within reach, but this was not followed in these cases.