Failure to Ensure Call Lights Were Accessible and Functional
Penalty
Summary
The facility failed to ensure that call lights were within reach and functioning properly for two residents, resulting in the potential for delayed or unmet care needs. For one resident with hemiplegia, impaired vision, and severe cognitive impairment, the call light was observed to be placed on a rolling table approximately three feet away from the bed, making it inaccessible. Both the LVN and ADON confirmed that the call light was not within reach and should have been placed closer to the resident's functional side to allow for timely assistance, as outlined in the resident's care plan. Another resident, assessed as high risk for falls due to impaired mobility and vision, reported that their call light had not been working for two days despite notifying staff. The resident stated that no staff responded to the call light and had to leave the room to seek assistance. The facility's policy required staff to ensure call lights were functional and to answer them promptly, but this was not followed, as evidenced by the resident's experience and staff interviews.