Failure to Ensure Call Light Accessibility for Residents with Mobility Impairments
Penalty
Summary
The facility failed to ensure that call lights were accessible to two residents, both of whom had significant mobility impairments. For one resident with a right femur fracture and difficulty walking, the call light was observed placed above the pillow and out of reach. The resident was unaware of the call light's location. A Licensed Vocational Nurse confirmed the call light was not accessible and subsequently placed it in the resident's hand. The Certified Nursing Assistant (CNA) responsible for this resident admitted she had not checked the call light's accessibility during her last round, despite facility policy requiring her to do so each time she entered the room. For another resident with hemiplegia and hemiparesis following a stroke affecting the right side, the call light was found wrapped around the right bedrail, hanging down and touching the floor, making it unreachable. This resident also did not know where the call light was. The CNA responsible for this resident stated she had not checked the call light's location during her last check, mistakenly believing it had been removed by maintenance. Maintenance staff clarified that call lights should not be wrapped around bedrails and should be accessible, and the Minimum Data Set Nurse confirmed that facility policy requires call lights to be within reach, especially for residents with weakness on one side.