Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as required by both the resident's care plan and facility policy. During an observation, the call device for a female resident with dementia, anxiety, and heart failure was found wrapped around the bed rail with the handle below mattress level, making it inaccessible. The resident was non-ambulatory and required partial to moderate assistance with mobility and self-care, according to her medical records and MDS assessment. Her care plan specifically included the intervention to keep the call light within reach at all times due to her high fall risk. Interviews with staff, including a CNA, LVN, DON, and the Administrator, confirmed that facility policy mandates call lights must always be within reach of residents. Staff acknowledged responsibility for ensuring call light accessibility and recognized that failure to do so could prevent residents from communicating their needs. The CNA could not recall recent training on call lights, and both the LVN and DON identified the call light in the surveyor's photo as being out of reach for the resident. The DON and Administrator reiterated that all staff, regardless of role, are responsible for checking call light placement before leaving a resident's room. The facility's policy and staff interviews consistently indicated that call lights are essential for residents to express their needs and request assistance. Despite this, the observed failure to keep the call light within reach for the resident placed her at risk of having unmet needs, as she was unable to contact staff when assistance was required. The deficiency was substantiated by direct observation, staff interviews, and review of the resident's care plan and facility policy.