Failure to Ensure Call Lights Accessible to Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two of nineteen sampled residents, as required by facility policy and individual care plans. For one resident with decision-making capacity, the call light was observed on the floor under the bed, out of reach, and the resident was unable to locate or use it. This was confirmed by both the resident and an LVN, who acknowledged the call light was not accessible and stated that it should be within reach for resident safety and communication. For another resident with severe cognitive impairment and a history of neurological weakness and confusion, the call light was found clipped to the wall, also out of reach. The resident was unable to locate or use the call light to request assistance and did not know who had placed it there. This was similarly confirmed by an LVN, who stated the call light should be accessible, and by the DON, who verified the findings. Both residents had care plans specifying that call lights should be within reach, but these interventions were not followed.