Call Lights Not Accessible for Residents at Risk for Falls
Penalty
Summary
The facility failed to ensure that call lights were accessible and within reach for residents at risk for falls and injury, as required by their Call Light Policy. During observations, call lights for three residents with significant mobility and cognitive impairments were found out of reach: one call light was on the floor next to the bed, another was under the bed frame near equipment, and a third was placed on top of an air pump at the foot of the bed. These residents had diagnoses including repeated falls, muscle weakness, hemiplegia, hemiparesis, major depressive disorder, insomnia, lack of coordination, seizures, muscle spasms, and contractures, all of which increased their vulnerability to accidents if unable to summon assistance. Interviews with CNAs confirmed that call lights should not be placed on the floor or at the foot of the bed, and that they should be secured within the resident's reach to allow them to call for help when needed. The Director of Nursing also stated that all call lights should be clipped to the resident's beds to ensure accessibility. The failure to follow these procedures resulted in call lights being inaccessible for all three residents reviewed, creating the potential for accidents and delayed response to resident needs.