Failure to Ensure Accessible Call Light System for Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure that a working call system was accessible to residents in their beds or other sleeping accommodations in five out of six rooms where residents were care planned for call bell use. Observations revealed that call bells were often out of reach, such as being hung on walls, hidden behind curtains, or placed on the floor under beds. Interviews with residents confirmed that some were unable to locate or access their call bells when needed, despite care plans specifying that call lights should be within reach and residents encouraged to use them. Staff interviews corroborated that call bells were not always accessible, and that staff were aware of the expectation to keep call lights within reach. In one case, a resident with dementia and behavioral issues had their call light removed due to repeated disconnection and aggressive behavior when staff attempted to restore it. The care plan and Kardex for this resident indicated that staff should anticipate needs because the resident could not use the call bell appropriately, but no alternate means of communication was provided after the call light was removed. The resident's medical history included dementia, wandering, delusional and adjustment disorders, depression, and anxiety, and the care plan noted risks related to communication and self-care deficits. Additional observations included a resident whose call light was found on the floor and another whose bed placement made the call light inaccessible. Staff confirmed these situations during interviews. The Staff Development Coordinator stated that staff are educated to ensure call lights are within reach and to respond promptly, and confirmed that call light cords should not be pinned up or removed. Despite these policies, the deficiency persisted across multiple rooms and residents.