Call Light System Not Accessible to Residents in Bed
Penalty
Summary
The facility failed to ensure that the call light system was accessible to residents while in bed or other sleeping accommodations for two of five residents reviewed for reasonable accommodation of needs. Observations revealed that one resident, who had a history of stroke, lack of coordination, moderate cognitive impairment, and required total assistance for activities of daily living, was found lying in bed with the call light pull cord hanging from the wall behind him and out of reach. The resident was unaware of the location of the call light. Another resident, with diagnoses of muscle weakness, unsteadiness, moderate cognitive impairment, and extensive assistance needs, was also observed lying in bed with the call light approximately three feet away and out of reach. This resident also did not know where the call light was and requested assistance from the surveyor. Interviews with multiple staff members, including LVNs, a CNA, and the DON, confirmed that call lights are expected to be within reach of residents and that it is the responsibility of all staff to ensure this during their rounds. Staff acknowledged that the call lights had clips to keep them in place, but these sometimes fell off or were moved during care activities such as meal delivery. The facility's policy on resident rights emphasized the importance of treating residents with dignity and ensuring their ability to communicate and access services, but there was no care plan intervention documented for one resident regarding call light use.