Failure to Maintain Call Lights Within Reach for Two Residents
Penalty
Summary
The facility failed to maintain call lights within reach for two residents, resulting in unmet needs and distress. One resident with Parkinson's disease, diabetes, dementia, and an overactive bladder was found lying in bed without a sheet or blanket, calling out for help. The call light was observed on the floor behind the headboard, out of the resident's reach. The resident reported feeling wet and unable to find the call light, expressing frustration and alleging that staff hid the call light due to frequent use. Both the RN and CNA assigned to the unit confirmed the call light was not in reach but denied intentionally placing it out of reach. Another resident with chronic atrial fibrillation, sick sinus syndrome, and a cognitive communication deficit was found in a recliner with a strong odor of urine in the room. The call light was on the floor, out of reach, and the resident described having to get up and walk around the bed to access it. The resident expressed difficulty in keeping the call light nearby and requested assistance. Multiple observations confirmed the call light remained unanswered for an extended period, and staff verified the call light was not accessible. Facility policy required call lights to be within reach and for staff to be attentive to resident needs.