Failure to Ensure Call Light Accessibility for Dependent Residents
Penalty
Summary
The facility failed to ensure that residents had access to their call light systems, which are necessary for requesting staff assistance, as required by their care plans and facility policy. During observations and interviews, it was found that three residents with severe cognitive impairment and significant physical limitations did not have their call lights within reach. In each case, the call light was observed on the floor, out of the resident's reach, and the residents were unaware of the location of their call lights when asked. Record reviews indicated that these residents were dependent on staff for all or substantial assistance with activities of daily living and were identified as fall risks. Their care plans specifically included interventions to ensure call lights were accessible. Despite this, staff interviews revealed that although there were procedures in place to check and clip call lights within reach during rounds, these procedures were not consistently followed, resulting in the call lights being inaccessible at the time of surveyor observation. Multiple staff members, including CNAs, LVNs, the DON, ADON, and the Administrator, acknowledged awareness of the importance of keeping call lights within reach and described ongoing efforts to remind staff of this requirement. However, the deficiency persisted, as evidenced by direct observation and staff admissions that call lights were not always secured or checked as required. The facility's own policy emphasized the necessity of ensuring call lights are accessible to residents when in bed, but this standard was not met for the three residents reviewed.