Failure to Ensure Call Light Accessibility for Two Residents
Penalty
Summary
The facility failed to ensure that two residents had access to their call lights, as required by their care plans and facility policy. For one resident with hemiparesis, muscle weakness, and moderate cognitive impairment, the call light was observed on the floor under the bed, and the resident was unaware of how it got there or what to do if assistance was needed. The resident's care plan specifically included an intervention to ensure the call light was within reach. For another resident with Parkinson's disease, bipolar disorder, anxiety disorder, and moderate cognitive impairment, the call light was found under the mattress, and the resident did not know its location, expressing concern about being able to call for help. A CNA assigned to both residents stated she did not know how the call lights became inaccessible but later clipped them to the bedspreads. She acknowledged that lack of access to the call light could lead to residents attempting to get up without assistance. The DON confirmed the importance of call light accessibility and stated that charge nurses monitor this during daily rounds. Facility policy requires staff to ensure call lights are within reach and secured as needed.