Failure to Ensure Call Lights Accessible to Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two of three sampled residents, resulting in both residents being unable to use their call lights to request assistance. For one resident with convulsions and muscle weakness, the call light was found wedged between the mattress and side rail, out of reach, causing the resident to yell for help and experience frustration due to difficulty moving and inability to reposition himself. The resident reported that this was a recurring issue and that he had to yell to get staff attention. A CNA confirmed that staff should have checked the call light's accessibility before leaving the room. Another resident, with diagnoses including fibromyalgia, back pain, and dementia, was observed sitting on the edge of her bed with her call light placed on a bedside table out of her reach. This resident also reported having to yell for assistance and expressed frustration both at her own inability to access the call light and at the frequent yelling from a neighbor, which disrupted her rest. The care plan for this resident specifically required the call light to be within reach due to her fall risk. Staff interviews confirmed that call lights should be accessible and that failure to do so could increase the risk of residents attempting to get up on their own.