Call Light System Inaccessible for Bed Bound Resident
Penalty
Summary
A deficiency was identified when a resident's call light system was found to be inaccessible, as the call button was located under the right positioning side rail and out of the resident's reach. The resident, who was bed bound and dependent on staff for assistance, was observed yelling and calling out for help because she could not access the call button. Staff interviews confirmed that the call button should have been within the resident's reach, and facility policy requires call cords to be placed within reach to enable residents to alert nursing staff from their rooms. The resident involved had a history of metabolic encephalopathy, glaucoma, heart failure, and was at risk for falls due to poor balance and unsteady gait. Her care plan specifically included the intervention to ensure the call light was within reach and to encourage its use for assistance. Despite these documented needs and interventions, the call system was not accessible at the time of the surveyor's observation, resulting in the resident being unable to summon help except by yelling.