Failure to Ensure Call Light Accessibility for Multiple Residents
Penalty
Summary
The facility failed to ensure that the nurse call system was accessible for three residents who required varying levels of assistance with activities of daily living (ADLs) and had significant medical conditions. Observations revealed that the call lights for these residents were found on the floor and out of reach while the residents were in bed. One resident, with severe cognitive impairment and muscle weakness, had her call light on the floor near the bedside table. Another resident, also with severe cognitive impairment and total dependence for ADLs, was unable to locate his call light and expressed a need for assistance to urinate. The third resident, who was a fall risk and required substantial assistance, had her call light under the nightstand and out of reach. Record reviews indicated that care plans for at least two of these residents specifically required that call lights be kept within reach and that residents be encouraged to use them. Staff interviews confirmed that call lights should be accessible to residents and acknowledged that the devices may have been knocked down during movement in bed. The facility's policy also required that call lights be accessible to residents when in bed, but this was not followed at the time of the observations.