Failure to Ensure Call Lights Were Accessible to Residents
Penalty
Summary
The facility failed to ensure that the call light system was accessible to several residents, as required by their care plans and facility policy. Observations and interviews revealed that five residents with severe cognitive and physical impairments did not have their call lights within reach while in their rooms. In multiple instances, call lights were found on top of side tables, inside drawers, on the floor, or even in a trash can, making them inaccessible to the residents. Staff interviews confirmed that the expectation was for call lights to be within reach at all times, but this was not consistently followed. The residents involved had significant medical and functional needs, including muscle weakness, lack of coordination, muscle wasting, atrophy, repeated falls, Alzheimer's disease, hemiplegia, diabetes, dementia, and rheumatoid arthritis. Their MDS assessments indicated severe cognitive impairment and dependence on staff for mobility and self-care. Care plans for these residents specifically included interventions to ensure call lights were within reach due to their high risk for falls and inability to independently seek assistance. Staff members, including CNAs, LVNs, RNs, the DON, and the Administrator, acknowledged during interviews that call lights are essential for resident safety and should be accessible at all times. Despite this, the deficiency was observed across multiple rooms and shifts, with staff sometimes unaware that call lights were not properly positioned. The facility's own policy required call lights to be placed within reach of residents' beds or sitting areas, but this was not consistently implemented, resulting in the deficiency.