Failure to Ensure Call Lights Within Resident Reach
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents with severe cognitive impairment and significant self-care deficits. For one resident with multiple sclerosis, atrial fibrillation, and Alzheimer's disease, observation revealed she was lying in bed calling for help, with her call light button hanging on the wall by the curtain approximately ten feet away. A CNA confirmed that the call button was not within her reach. The resident's care plan required staff to encourage her to use the call light when assistance was needed, and facility policy stated that each resident should have a means to call staff directly from their bed. Another resident with chronic obstructive pulmonary disease, Parkinson's disease, and vascular dementia was observed sitting in a wheelchair in his room, approximately five feet from his bed where the call light was positioned. The DON confirmed that the call light button was out of the resident's reach. Both residents' care plans included interventions to encourage use of the call light for assistance, and the facility's policy required accessible call systems for residents. These observations and interviews demonstrated that the facility did not follow its own policy or the residents' care plans regarding call light accessibility.