Failure to Ensure Accessible Call Light System for Residents
Penalty
Summary
The facility failed to ensure that the nurse call system was accessible for residents to call for staff assistance, as required. Observations on multiple halls revealed that the call lights in the rooms of seven residents were not within their reach. In several cases, the call lights were found hanging over chairs, on the floor, on top of wheelchairs, or behind beds, making it impossible for the residents to access them when needed. These findings were confirmed during observations conducted by surveyors on the same day. The residents affected had significant medical histories, including muscle weakness, lack of coordination, repeated falls, and varying levels of cognitive impairment as indicated by their BIMS scores. Their care plans specifically included interventions to ensure that call lights were within reach due to their high risk for falls and need for assistance with activities of daily living (ADLs). Despite these documented needs, the call lights were not positioned appropriately at the time of the survey. Interviews with nursing staff, including LVNs and RNs, confirmed that the expectation was for call lights to be within reach of residents and that staff were supposed to check this during their rounds. Staff acknowledged that call lights could be moved or knocked off by residents, but also stated that they had procedures, such as using clips, to keep them accessible. The interim DON reiterated the expectation for call lights to be within reach and for staff to check their placement during rounds. Review of the facility's policy also confirmed the requirement for call lights to be accessible to residents when in bed.