Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that a working call system was available and within reach for residents in their rooms, specifically for two residents with significant medical and cognitive needs. Observations revealed that one resident's call light was found on the floor under the bed while the resident was lying in bed, and another resident's call light was on a bedside table, out of reach, while the resident was also in bed. Both residents had care plans that required the call light to be within easy reach and for staff to remind or encourage them to use it for assistance as needed. Record reviews indicated that both residents had multiple diagnoses, including dementia, heart failure, and a history of falls, and required partial to moderate assistance with transfers and daily activities. Their care plans specifically included interventions for fall prevention and safety, such as ensuring the call light was within reach and checking on the residents at routine intervals. Despite these documented needs and interventions, staff failed to maintain the call lights within reach, as observed during the survey. Interviews with staff, including CNAs, LVNs, the DON, and the ADM, revealed inconsistent understanding and implementation of call light placement policies. While staff stated that the expectation was for call lights to always be within reach and that all staff were responsible for ensuring this, there was no formal written policy in place. Staff also acknowledged that failure to keep call lights within reach could result in residents being unable to call for help, but could not explain why the deficiency occurred for the two residents in question.