Call Lights Not Accessible to Residents
Penalty
Summary
Facility staff failed to ensure that call lights were within reach for five residents in rooms reviewed for call light placement. Observations revealed that call lights were found on the floor at the foot or head of the bed, or otherwise unreachable, for multiple residents. One resident, who had severe cognitive impairment and diagnoses including muscle weakness, sequelae of cerebral infarction, dementia, and hypertension, was observed lying in bed with the call light on the floor and reported being left wet after urinating on herself, stating that staff took the call light away and were slow to respond to her needs. Other residents' call lights were similarly found out of reach during the same observation period. Interviews with staff indicated that some were aware of the call lights being on the floor but did not take action to make them accessible to the residents. A CNA in training acknowledged the issue but did not correct it, and another CNA stated that the cognitively impaired resident often pulled her call light out of the wall. The facility's policy requires that call lights be within reach and accessible in resident rooms, bathrooms, and bathing areas, but this was not followed for the residents observed.