Inaccessible Bathroom Call Light Cords for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s resident call system related to bathroom and bathing areas. The facility’s policy titled “Call System, Residents” states that each resident must be provided with a means to call staff directly for assistance from toileting/bathing facilities and from the floor, and that the resident call system remains functional at all times. However, during observations in two shared bathrooms, the red pull cords for the call lights were found to be too short to be reached from the floor, contrary to the facility’s policy. The deficiency involved ten sampled residents who used these bathrooms. These residents had multiple medical diagnoses and varying levels of cognitive impairment and functional dependence. For example, one resident with metabolic encephalopathy, schizophrenia, and moderately impaired cognition required substantial/maximal assistance with bathing, personal hygiene, toilet use, and lower body dressing. Other residents had conditions such as acute respiratory failure with hypoxia, major depressive disorder, generalized anxiety disorder, history of falls, unsteadiness on feet, difficulty in walking, Alzheimer’s disease, metabolic encephalopathy, heart failure, and cognitive communication deficits, with many having moderately or severely impaired cognition. During an interview and observation in one resident’s room, the resident reported having fallen on the bathroom floor and being unable to reach the red pull cord to call for help. Subsequent observations in the shared bathrooms confirmed that the red pull cords did not reach the floor. Certified Nursing Assistants acknowledged during concurrent observations and interviews that the pull cords were too short and could not be reached from the floor by a resident in an emergency, and described this as a safety issue when a resident falls and cannot call for help. The Maintenance Assistant also acknowledged that all red pull cords in the bathrooms were too short in length for residents to reach from the floor.
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