Failure to Ensure Call Lights Were Within Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure that three residents had their call lights within reach, as required by their care plans and facility policy. Observations on the specified date revealed that the call lights for these residents were either hanging towards the floor, placed behind the bed against the wall, or located near a nightstand out of reach. At the time of these observations, the residents were either asleep or, in one case, calling out for assistance because the call light was not accessible. Interviews with the residents confirmed that their call lights were frequently not within reach, requiring them to yell or seek staff assistance directly. One resident specifically stated that the call lights were never within reach and that residents often had to yell or find staff when they needed help. Staff interviews corroborated these findings, with both CNAs and the DON acknowledging that it was the responsibility of all staff to ensure call lights were accessible, and that failure to do so would prevent residents from calling for assistance. Record reviews indicated that each resident had care plans specifying the need for call lights to be within reach due to their medical conditions, such as rheumatoid arthritis, muscle weakness, dementia, parkinsonism, morbid obesity, and chronic obstructive pulmonary disease. The facility's policy also required staff to ensure call lights were accessible to residents at all times. Despite these documented requirements, the deficiency was observed for three residents, placing them at risk of unmet needs.