Failure to Ensure Call Light Accessibility for Dependent Residents
Penalty
Summary
The facility failed to ensure that the call light was within reach for two residents, both of whom had significant medical conditions and were dependent on staff for assistance with activities of daily living. For one resident with diagnoses including diabetes mellitus, osteoarthritis, hypertension, metabolic encephalopathy, muscle weakness, and failure to thrive, the call light was observed on the floor by the roommate’s nightstand, out of the resident’s reach. Staff, including a CNA and the Activities Director, were unable to locate the call light initially, and the Activities Director confirmed that the call light should be within the resident’s reach. Multiple staff interviews, including with an LVN, RN Supervisor, and the DON, confirmed that the call light should always be accessible to the resident to ensure their needs are met and to minimize fall risk. Another resident, admitted with difficulty walking, muscle weakness, history of falls, and age-related cataract, was also found with the call light on the floor and out of reach while lying in bed with bed rails up. The DON observed this and placed the call light within the resident’s reach, acknowledging the risk for unattended needs and falls. The resident’s care plan included interventions to keep the call light within reach and to encourage its use for assistance, reflecting the resident’s impaired vision and need for help with self-care and mobility. A review of the facility’s policy and procedure titled “Answering the Call Light” indicated that when a resident is in bed or confined to a chair, the call light should be within easy reach. Both residents’ care plans also specified the need for the call light to be accessible. The observations and staff interviews confirmed that the facility did not follow its own policy and care plan interventions, resulting in the call light being out of reach for these two residents.