Failure to Ensure Call Lights Within Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for four residents, as required by their care plans and facility policy. Observations revealed that the call lights for these residents were either clipped to privacy curtains or cords coming out of the wall, making them inaccessible from the residents' beds. Staff interviews confirmed that the residents were unable to reach their call lights to request assistance when needed. The affected residents had significant medical and cognitive impairments. One resident had hemiplegia following a stroke and was dependent on staff for most activities of daily living, while another had severe cognitive impairment and an indwelling catheter. Additional residents had diagnoses including dementia, metabolic encephalopathy, and reduced mobility, with varying levels of independence but all identified as being at risk for falls. Their care plans specifically included interventions to ensure call lights were within reach and to encourage their use for assistance. Despite these documented needs and interventions, staff failed to position the call lights appropriately, as verified during multiple observations and staff interviews. The facility's own policy required that each resident be provided with a means to call staff directly for assistance from their bed, but this was not followed for the four residents reviewed.