Failure to Ensure Call Lights Were Within Reach for Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for residents who required assistance, as observed in three separate cases. One resident with diabetes, hypertension, anxiety, depression, bipolar disorder, and chronic kidney disease was found lying in bed calling for help with the call light on the floor and out of reach. This was confirmed by a CNA and later by an LPN, who found the resident still unable to access the call light and needing assistance to get dressed. The resident's roommate also needed help and had activated the call light, which was not accessible to the resident. Another resident with acute respiratory failure, catatonic disorder, dysphagia, major depressive disorder, multiple contractures, and dependence on supplemental oxygen was observed unable to perform any self-care and used a pressure pad call light. The call light was found on the floor, out of reach, and the CNA had to reposition it next to the resident's contracted arm. A third resident with severe infections, morbid obesity, malnutrition, chronic kidney disease, and muscle weakness was also unable to reach the call light, which was wrapped around the bed rail and out of reach. The CNA confirmed this and repositioned the call light within reach. Facility policy requires that call lights be within easy reach for residents in bed or confined to a chair.