Failure to Ensure Call Light Accessibility for Two Residents
Penalty
Summary
The facility failed to ensure that two residents had access to their call light systems, as required by their care plans and facility policy. For one resident with a history of left femur fracture and moderate cognitive impairment, the call light was found inside her nightstand and not within her reach while she was lying in bed. The resident was unable to identify the location of her call light when asked. For another resident with severe cognitive impairment and muscle weakness, the call light was located on the side of the bed against the wall, also out of reach, and the resident did not know where it was. Both residents required substantial assistance with activities of daily living and had care plans specifying that call lights should be within reach. Multiple staff interviews confirmed that call lights are expected to be within reach of all residents and that staff are responsible for checking this during regular rounds. Despite these expectations and documented in-service training on the subject, observations on the day of the survey revealed that the call lights for both residents were not accessible. Staff acknowledged the importance of call light accessibility for resident safety and indicated that rounds were conducted to check for this, but the deficiency was still observed during the survey.