Failure to Ensure Call Lights Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure that two residents had their call lights within reach, as required by their care plans and facility policy. For one resident, who had diagnoses including non-Alzheimer's dementia, stroke, spinal stenosis, and muscle weakness, the call light was observed hanging behind the right side of the bed, out of reach, while the bed controls were accessible. The resident reported that staff sometimes did not return the call light to her reach after providing assistance, and she would wave at staff passing by to get help if she could not reach the call light. Her care plan specifically required that the call light and bed controls be within reach at all times to mitigate her risk for falls and injuries. Another resident, with severe cognitive impairment and multiple medical conditions such as heart failure, neurogenic bladder, and respiratory failure, was found with his call light behind the bed and nightstand, tangled among other cords and not accessible. He stated he often had to yell for help because the call light was not on his bed. Staff interviews confirmed that it was the nurses' responsibility to ensure call lights were within reach and that all staff were expected to check call light placement. The facility's policy required call lights to be accessible and within reach of the resident's bed or sitting area, but this was not followed for these two residents.