Failure to Ensure Call Lights Within Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure that three residents had their call lights within reach, as required by their care plans and facility policy. Observations on a specific date revealed that the call lights for these residents were either hanging towards the ground or placed several feet away, making them inaccessible. Two of the residents were unable to reach their call lights and reported having to yell or physically move to get assistance, while the third resident could not be interviewed due to severe cognitive impairment. Record reviews indicated that all three residents had significant medical conditions and varying levels of cognitive impairment, with care plans specifically instructing staff to keep call lights within reach and encourage their use. Staff interviews confirmed that call lights were not always returned to accessible positions after care was provided. One CNA admitted to moving a call light and forgetting to return it, while another was unaware that a call light was out of reach. Both acknowledged that this could prevent residents from calling for help. Interviews with facility leadership, including the DON and ADM, confirmed that it is the responsibility of all staff to ensure call lights are always within reach of residents. The facility's policy also requires that call lights be easily accessible to residents in bed or confined to a chair. The deficiency was identified through observation, interview, and record review, demonstrating a failure to provide reasonable accommodations for resident needs and preferences as required.