Failure to Ensure Accessible Call Light System for Residents
Penalty
Summary
The facility failed to ensure that three residents had access to a working and reachable call light system, as required for their safety and accommodation of needs. Observations revealed that one resident's call light pad was on the floor, out of reach while the resident was in bed. Another resident, who was at high risk for falls and had their bed placed on the floor, had their call light hanging over a light fixture several feet above and out of reach. A third resident, who was blind and required assistance for transfers and toileting, was unable to locate her call light, which was found tucked away in a closed nightstand drawer, inaccessible to her. Interviews with staff confirmed that these residents were able to make their needs known and required the use of their call lights for assistance, especially given their high fall risk, cognitive impairments, and physical limitations. Staff acknowledged the importance of keeping call lights within reach and stated that it was the facility's expectation for all staff to ensure this. The residents' care plans also specifically included interventions to keep call lights accessible and to encourage their use for requesting help. Record review of the facility's policy on answering call lights indicated that call lights should be plugged in, functioning, and accessible to residents at all times, including when in bed, on the toilet, in the shower, or on the floor. Despite these policies and care plan interventions, the facility did not ensure that the call lights were within reach for these residents, as directly observed and confirmed through staff and resident interviews.