Failure to Ensure Accessible Call Light System for Residents
Penalty
Summary
The facility failed to ensure that a working call system was available and within reach for residents in their rooms, specifically for two residents with significant cognitive and physical impairments. Observations revealed that the call light buttons for both residents were found on the floor under the head of their beds, making them inaccessible. Staff interviews confirmed that the call lights were not within reach, and staff acknowledged that this would prevent the residents from calling for help if needed. One resident, a male with moderate cognitive impairment, muscle weakness, and a history of falls, was observed lying in bed without access to his call light, which was on the floor. He was unaware of the location of his call light and expressed a desire to call for assistance. A staff member found the call light on the floor and placed it within his reach, noting that the resident would not have been able to call for help in case of an emergency or incontinence. Another resident, a female with severe cognitive impairment, muscle weakness, and a history of falls, was also found sleeping in bed with her call light on the floor and out of reach. A CNA entered the room, found the call light on the floor, and placed it within the resident's reach, stating that the resident would not have been able to call for help if needed. Facility leadership and policy confirmed the expectation that call lights should always be within reach of residents to allow them to request assistance.