Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure resident call lights were accessible as required by facility policy. One male resident with mild cognitive impairment was observed in his wheelchair with approximately four meters of call light string trapped under the wheelchair wheel, preventing him from triggering the call; he stated his call light was not working because the string was too long and trapped. Another female resident with severe cognitive impairment was observed lying in bed A while the call light string was located in bed B, out of her reach. A third female resident with moderate cognitive impairment was observed in bed with her call light on the floor, and she stated she could not access it. A fourth female resident with intact cognition was observed in her room with a broken call light string on the wall that was only about one foot long and could not reach her. A fifth female resident with intact cognition was observed in bed with a call light hanging from the wall; she stated that her call light was not hooked up to her bed so she could not use it to call. Staff interviewed, including an LPN, an RN, and the DON, acknowledged that call lights should be accessible to residents so they can call for help. The facility’s undated call light policy stated that staff are to place the call light where the resident can reach it, but observations showed this was not consistently done for the five residents reviewed.
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