Failure to Ensure Call Lights Accessible to Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible to three residents who were reviewed for reasonable accommodation of needs. Observations on the specified date revealed that one resident's call light was placed on top of a side table and not within reach while the resident was in bed with eyes closed. Another resident's call light was found inside a drawer, making it inaccessible while the resident was eating breakfast in bed and unable to locate it when asked. A third resident's call light was observed on the floor, and the resident reported not being able to find or see the call light cord, expressing concern about what would happen if he needed help and could not leave the room. Record reviews indicated that all three residents had care plans specifying that call lights should be within reach due to their risk for falls and varying levels of cognitive and physical impairment. The residents' medical histories included diagnoses such as muscle weakness, lack of coordination, and severe to moderate cognitive impairment, with some being dependent on staff for activities of daily living. Staff interviews confirmed that the expectation was for call lights to be within reach at all times, and that staff were responsible for ensuring this during rounds and after providing care. Despite these policies and care plan interventions, staff failed to consistently ensure call lights were accessible. Staff members interviewed acknowledged the importance of call lights for resident safety and communication, and admitted to not always checking their placement. The facility's written policy also required that call devices be left within the resident's reach before staff left the room, but this procedure was not followed for the residents involved in the deficiency.