Call Light Not Kept Within Reach for Resident
Penalty
Summary
The facility failed to ensure that the call light was kept within reach for one of three randomly selected residents. Resident 3, who was cognitively intact and required partial to moderate assistance with activities of daily living, was observed and interviewed after she had been calling out for help for approximately four hours without response. The call light, which is the primary method for residents to request assistance, was found on the floor and out of her reach. Resident 3 reported that this was a common occurrence and that she was unable to get help when needed, specifically mentioning discomfort due to bunched-up clothing that she could not adjust herself. Staff interviews confirmed that the call light was not accessible to the resident, and both the Registered Nurse Supervisor and the Director of Nursing acknowledged that call lights must be within reach to allow residents to request assistance for their needs. A review of the facility's policy and procedures also indicated that staff are required to ensure call lights are accessible to residents at all times. The failure to keep the call light within reach was directly observed and confirmed by staff, and was not in accordance with the facility's established procedures.