Failure to Ensure Accessible Nurse Call System for Multiple Residents
Penalty
Summary
The facility failed to ensure that the nurse call system was accessible for six out of ten residents reviewed for call system access. Observations on the specified date revealed that the call lights in the rooms of these residents were not within their reach. In several cases, the call lights were found hanging from the bed near the floor, on the floor under or behind the bed, or on another bed in the room, making it impossible for the residents to access them when needed. The residents affected had significant medical histories, including severe cognitive impairment, muscle weakness, repeated falls, lack of coordination, and difficulty walking. Their care plans specifically included interventions to ensure the call light was within reach and to encourage use of the call system. Despite these documented needs and interventions, staff did not consistently ensure the call lights were accessible, as evidenced by direct observations and resident interviews. One resident with intact cognition was observed nearly falling while trying to retrieve her call light from the floor. Interviews with staff, including LVNs, CNAs, the ADON, and the DON, confirmed that call lights should be within reach of residents and that staff are expected to check call light placement during rounds. Staff acknowledged the importance of call light accessibility and recognized that the observed situations did not meet facility expectations or policy. The facility's policy states that residents are to be provided with a means to call staff for assistance through a communication system, but this was not consistently implemented.