Failure to Provide Accessible and Functioning Call Lights to Residents
Penalty
Summary
The facility failed to ensure that residents had functioning call lights within their reach, as observed in six out of nine residents reviewed for accommodation of needs. In one shared room, only one call light was present and it was positioned closer to one bed, leaving the other resident without access. One resident reported having to pull the call light closer to his bed, while his roommate had no call light and had to yell or leave the room to seek assistance. The Director of Nursing confirmed the absence of a call light for one resident and was unsure why only one was available in the room. Another resident was found asleep in her wheelchair with her call light on the floor behind her bed, out of reach, and the Assistant Director of Nursing acknowledged it should have been clipped to her wheelchair. Additional residents reported non-functioning call lights or a complete lack of access, with one resident stating her call light had not worked since admission and that she had informed multiple staff members without any follow-up. Further observations revealed that some residents' call lights were several feet away and inaccessible, despite their limited mobility and medical conditions such as multiple sclerosis, stroke-related paralysis, dementia, and Alzheimer's disease. The facility's policy requires that call lights be within easy reach of residents in bed or confined to a chair, and that defective call lights be promptly reported to maintenance. However, these procedures were not followed, resulting in multiple residents being unable to summon assistance as needed.