Failure to Ensure Call Lights Are Accessible to Residents
Penalty
Summary
The facility failed to ensure that call lights were consistently within reach for multiple residents who required assistance, as observed through direct observation, interviews, and record review. Several residents with significant medical conditions and varying levels of cognitive impairment were found with their call lights placed out of reach, sometimes on the floor, on bedside tables several feet away, or wrapped around bed lights. In some cases, residents were unable to summon help due to the inaccessibility of their call lights, and staff did not always respond to verbal requests for assistance. Specific examples include a resident with chronic respiratory failure and moderate cognitive impairment whose call light was repeatedly found three feet away while she was in bed, and another resident with vascular dementia and a history of falls whose call light was similarly out of reach. One resident, dependent for transfers and at risk for falls, was observed with her call light on the floor, and the cord was not long enough to reach her recliner. Residents and staff reported that call lights were sometimes intentionally placed out of reach, with one resident stating that staff would hide her call light or put it where she could not access it, and a CNA confirming that it was common practice to take away call lights from certain residents. The facility's own policy requires that call lights be available and easily accessible to all residents capable of using them, and that maintenance be notified if the call light cord is not long enough. Despite this, multiple observations and interviews confirmed that call lights were not consistently kept within reach, and some residents had to rely on others to turn on their call lights or resorted to yelling for help when they could not access them. Family members and staff corroborated that this was a recurring issue affecting several residents.