Failure to Ensure Call Light Accessibility for Dependent Residents
Penalty
Summary
The facility failed to ensure that the call light system was accessible to three residents who required assistance, as observed during a survey. For one resident with a history of stroke, muscle weakness, and total dependence on staff for activities of daily living, the call light was found on the floor near the nightstand, out of reach while the resident was lying in bed. A registered nurse confirmed uncertainty about the resident's ability to use the call light and acknowledged that staff should ensure call lights are within reach during rounds. Another resident with severe cognitive impairment and reduced mobility was observed with the call light under the bed and out of reach, despite care plan interventions specifying the need for the call light to be accessible and for staff to encourage its use. A third resident, who had a displaced fracture, reduced mobility, and was a fall risk, was found with the call light hanging off a side rail and nearly touching the floor, also out of reach. The resident was unaware of the call light's location. Interviews with nursing staff, including an LVN and the DON, revealed that staff often forgot to return the call light to an accessible position after providing care, and that this oversight could prevent residents from calling for help. The facility's policy requires that each resident be provided with a means to call staff for assistance from their bed and other locations, but this was not consistently followed for the residents observed.