Failure to Maintain Accessible Call Lights for Two Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure that call lights were within reach of residents who were able to use the call light system. For one resident with multiple sclerosis, lack of coordination, and epilepsy, the care plan specified that the resident could use the call light when it was placed in the right hand with a Velcro strap attached to the call light cord and wrapped around the hand, allowing activation with the chin. During observation, this resident was seated upright in a wheelchair with the call light lying on the floor out of reach. A CNA confirmed the call light was out of reach and placed it in the resident’s right hand, but there was no Velcro strap attached. Subsequent observation showed the resident making multiple attempts to press the call light with the chin, but the device fell from the resident’s grasp onto the floor, again without any Velcro strap visible. An RN unit manager and a psychiatric nurse practitioner both verified that the call light had been out of reach on arrival and that the Velcro strap, which was supposed to be in use, could not be located in the room. A second resident, with diagnoses including ALS, respiratory failure with hypercapnia, and Parkinson’s disease, was observed in bed with the call light placed on the bedside nightstand, out of reach. An LPN confirmed that the call light was not within the resident’s reach and then moved it onto the resident’s stomach. In interviews, the DON and the Administrator confirmed that the facility’s expectation was that residents returning to their rooms after care and ADL assistance would be provided with a call light using the tools required per their individual care plans. Review of the facility’s Nurse Call System Policy stated that the facility would provide a means for residents to make staff aware of care needs at all times, including use of modified devices when needed. The observations and interviews showed that, for these two residents, the call light system was not maintained within reach or in the manner required by their care plans and facility policy.
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