Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the resident call system was accessible to allow residents to call for staff assistance through a communication system that relays the call directly to a staff member or a centralized staff area. Observations on a specific date revealed that four residents had their call lights positioned out of reach while they were lying in bed. For example, one resident's call light was found on the floor under a fall mat, another's was at the foot of the bed, and two others had their call lights hanging over the headboard or bottom bed frame, all out of reach. Record reviews for these residents showed that they had significant medical conditions such as muscle weakness, unsteadiness on their feet, and a history of falls. Their care plans specifically included interventions to ensure the call light was within reach due to their fall risk and need for assistance. Despite these documented needs, the call lights were not accessible at the time of observation. Interviews with CNAs and nursing staff confirmed that call lights are supposed to be within reach of residents and that staff are expected to check this during rounds. Staff acknowledged that sometimes call lights are not repositioned after care is provided, which can leave residents unable to contact staff if they need help. The facility's policy also requires call lights to be accessible at all times, but this was not consistently followed for the residents observed.