Failure to Ensure Call Light Accessibility for Multiple Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible to four residents, resulting in their inability to call for assistance and the potential for unmet care needs. Observations revealed that one female resident with Alzheimer's disease, diabetes, bilateral femur fractures, and dementia was found in her room with her call light hung over the back of her bed's headboard and her water out of reach. She was observed sliding down in her chair and attempting to get up without assistance. When the call light was pressed, it did not illuminate in the hallway, and staff had to be hailed from the nurse's station. The Maintenance Director later discovered that the call light system was malfunctioning, with bulbs blowing and the panel not lighting up, and noted the system was very old and in disrepair. Another male resident with a history of femur fracture, stroke, and poor cognition was observed lying in bed with his call light not visible and his water out of reach. He was later seen leaning out of bed, attempting to hand a cup to the surveyor, with his call light found under the foot of his bed. Staff interviews indicated that the call light had been given to him earlier, but it was not in reach when needed. The Assistant Director of Nursing confirmed that staff were expected to ensure call lights were in reach when leaving residents' rooms. A third male resident with dementia, diabetes, and muscle weakness experienced an unwitnessed fall from bed. Staff found his call light bunched up behind his blankets at the foot of the bed, out of reach. A fourth male resident with dementia and a history of falls was observed multiple times seated in a chair or wheelchair with his call light placed on the bed or hanging off the side of the bed, out of his reach. Staff interviews confirmed that call lights and water should be placed within reach, but this was not consistently done for these residents.