Failure to Ensure Call Lights Within Reach for Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights were placed within reach for three of nine sampled residents, as observed during multiple room visits. In one instance, a resident with hemiplegia, blindness in one eye, and epilepsy was found unable to reach the call light, which was tangled on the bed's siderail. The resident expressed the need for the call light to be accessible to request assistance, such as for water. A CNA confirmed the call light should be within reach and corrected the placement during the observation. Another resident, who was asleep and had diagnoses including cerebral ischemia and muscle weakness, was found with the call light hanging outside the bed and not accessible. The CNA placed the call light in the resident's hand upon noticing this. Both residents were dependent on staff for activities of daily living, transfers, and bed mobility, with one having cognitive impairment. A third resident, also dependent for ADLs and with cognitive impairment, was observed with the call light placed on top of the nightstand, out of reach. An LVN acknowledged that the call light should have been closer to the resident. Staff interviews confirmed that all facility staff are responsible for ensuring call lights are accessible and for responding to them promptly. Review of facility policy indicated that call lights must be accessible to residents when in bed, on the toilet, or during bathing.