Failure to Ensure Resident Call Lights Were Accessible
Penalty
Summary
The facility failed to ensure that the resident call light system was accessible to residents in their rooms, as required by facility policy. During observations, four residents with significant mobility limitations and severe cognitive impairments were found to have their call lights out of reach. In each case, the call light was either on the floor, under the bed, or otherwise not accessible to the resident, despite care plans specifying that call lights should be within reach due to their high risk for falls and need for assistance with activities of daily living (ADLs). Staff interviews revealed that the call lights were not returned to accessible positions after care activities such as bathing. In one instance, a restorative aide admitted to forgetting to place the call light within reach after bathing a resident. Other staff members, including CNAs and an LVN, were either unaware of why the call lights were not accessible or acknowledged that it was the responsibility of nursing staff to ensure call lights were within reach. The Director of Nursing confirmed that all staff should be checking to ensure call lights are accessible to residents. Record reviews for the affected residents showed that each had care plans and assessments indicating severe cognitive and physical impairments, requiring substantial or total assistance for ADLs. The facility's own policy required that residents be provided with a means to call staff for assistance from their beds, bathrooms, and bathing areas, but this was not consistently implemented, as evidenced by the observations and staff interviews.