Failure to Ensure Functional and Accessible Call Light System
Penalty
Summary
The facility failed to ensure that the call light system was functional and accessible for several residents, as observed through direct observation, interviews, and record review. One resident with dementia, muscle weakness, and a history of falls was found to have a non-functioning call light at her bedside, and she was unaware that it was not working. Her care plan specifically required a working and reachable call light due to her fall risk. Another resident with Down Syndrome and dementia was observed with her call light out of reach, placed under her pillow, contrary to her care plan instructions that it should be within reach and staff should encourage its use. Additional observations revealed that a resident with Alzheimer's disease and heart conditions had her call light more than three feet away while she was sleeping in an easy chair, making it inaccessible. A fourth resident with dementia, diabetes, and dysphagia could not reach his call light because it was hanging off the side of the bed, and he was unsure how often staff checked on him. Staff interviews confirmed that they were unaware of the non-functioning or inaccessible call lights, and in one case, a CNA replaced a non-working call light after it was discovered during the survey. Facility leadership, including the Maintenance Supervisor, DON, ADON, and Administrator, acknowledged that call lights are required to be within reach and functional at all times. The facility's policy also mandates that call lights be accessible, demonstrated to residents, and checked for functionality. However, staff interviews revealed that call lights were not routinely tested during daily rounds, and there was a lack of consistent monitoring to ensure compliance with these requirements.