Failure to Ensure Call Light Accessibility for Multiple Residents
Penalty
Summary
The facility failed to ensure that the call light system was accessible to five residents who required varying levels of assistance and were at risk for falls. Observations on a specific date revealed that the call lights in the rooms of these residents were not within their reach. In several cases, the call lights were found on the floor, under beds, behind side tables, or otherwise out of reach, despite care plans specifying that call lights should be accessible to the residents at all times. The residents involved had significant medical conditions, including muscle weakness, hemiplegia, hemiparesis, and abnormalities of gait. Some residents had severe cognitive impairments, as indicated by low BIMS scores, and required maximal or moderate assistance with activities of daily living such as dressing, bed mobility, and transfers. During interviews and observations, some residents were unable to locate their call lights or did not respond when asked about them, while others confirmed that their call lights had been out of reach for some time. Staff interviews confirmed that it was the responsibility of all staff members, including CNAs, LVNs, the ADON, and the DON, to ensure that call lights were within reach of residents at all times. Staff acknowledged that call lights are essential for residents to request assistance or alert staff in case of need. Facility policy and in-service training materials also specified that call lights should always be within residents' reach, but this expectation was not met during the observations documented in the report.