Failure to Ensure Call Devices Within Reach for Multiple Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure that call devices were within reach for three out of five sampled residents. Observations and interviews revealed that the call light system in the room shared by these residents was not functioning, as evidenced by the lack of illumination at the nurses' station panel. One resident was provided with a table bell as an alternative means to alert staff, while the other two residents had no alternate method to summon assistance. The Registered Nurse Supervisor confirmed that staff would not be aware of residents' needs in a timely manner due to the malfunctioning call light system. Record reviews showed that all three residents had care plans specifying that call lights should be within easy reach and answered promptly, particularly due to their diagnoses and levels of cognitive and physical impairment. The residents involved had conditions such as dementia, Alzheimer's disease, Guillian-Barre syndrome, and severe cognitive impairment, and required varying levels of assistance with activities of daily living. The facility's own policy, revised in October 2024, also required that call lights be within easy reach for residents in bed or confined to a chair.