Call Lights Not Accessible to Residents Requiring Total Assistance
Penalty
Summary
The facility failed to ensure that call light systems were accessible to residents who required total assistance and were identified as fall risks. During observations, three residents with moderate to severe cognitive impairment and significant physical limitations were found with their call lights out of reach. One resident's call light was under the bed, another's was approximately three feet away from the bed, and a third resident's call light was hanging behind the bed frame. These residents' care plans specifically included interventions to keep call lights within reach and encourage their use. Staff interviews confirmed that call lights were not always placed within reach, despite facility policy and care plan requirements. Certified nursing assistants and licensed vocational nurses acknowledged the importance of call light accessibility and stated that staff were expected to check rooms regularly to ensure compliance. The Director of Nursing also confirmed that call lights should be within reach and that measures such as clips had been implemented to help maintain their placement. However, on the day of the survey, the call lights for these residents were not accessible, contrary to both policy and individualized care plans.