Failure to Keep Call Lights Within Reach for Multiple Residents
Penalty
Summary
The facility failed to keep the call light within reach for three residents who were reviewed for accommodation of needs and preferences. For one resident with a history of osteoporosis, traumatic fracture, chronic delirium, and high fall risk, the call light was observed placed on the foot of the bed, out of reach while the resident was in a wheelchair. Staff interviews confirmed that the call light was not accessible and acknowledged that the resident could not reach it, which was contrary to the care plan intervention requiring the call light to be within easy reach and answered promptly. Another resident, admitted with mild cognitive impairment, a left shoulder fracture, and osteoporosis, was also found with the call light placed on the foot of the bed while in a wheelchair. The resident's care plan included an intervention to keep the call light within easy reach due to high fall risk. Staff interviews confirmed the call light was not accessible and that the resident could not reach it, despite the facility's policy requiring call cords to be placed within the resident's reach. A third resident, diagnosed with Alzheimer's disease, dementia, and functional quadriplegia, was observed lying in bed with the call light placed at the uppermost edge of the bed, out of reach. The resident's care plan required the call light to be within easy reach to minimize the potential for falls or injury. Staff acknowledged that the call light was not within reach and that this oversight could delay meeting the resident's needs. Facility policies reviewed indicated that all residents should have immediate access to a functioning call light at all times, and that call cords must be placed within reach in resident rooms.