Failure to Ensure Call Lights Within Reach for Dependent Residents
Penalty
Summary
The facility failed to ensure that three residents had their call lights within reach, as required by their care plans and the facility's own policy. Observations and interviews revealed that one resident was found lying in bed with the call light on the floor, out of reach and not visible to her. She stated she needed assistance to get out of bed and would have to wait for staff to check on her if she needed help, as she could not reach or see the call light. Another resident was observed in bed with the call light on the floor, three feet away, and he was unaware it had fallen. He stated he could not get up and would have to wait for staff rounds or try to shout for help in an emergency. A third resident, who was dependent for all self-care and unable to move independently in his wheelchair, was observed with the call light placed on the bed frame on the opposite side of the room, out of his reach. Staff interviews confirmed that the call light was not accessible to him and acknowledged the risk of injury or unmet needs when call lights are not within reach. Multiple staff members, including CNAs, RNs, the ADON, and the DON, stated that call lights are to be kept within reach of residents at all times, and that staff are responsible for monitoring their placement during regular rounds. Record reviews for all three residents showed significant physical and/or cognitive impairments, with care plans specifically directing that call lights be kept within reach to accommodate their needs and reduce fall risk. Despite these documented requirements and staff awareness, the facility did not ensure compliance, resulting in residents being unable to request assistance as needed. The facility's policy also required call lights to be within easy reach for residents in bed or confined to a chair, which was not followed in these cases.