Failure to Keep Call Lights Within Reach for Dependent Residents
Penalty
Summary
The deficiency involves staff failure to ensure resident call lights were accessible as required by facility policy and resident care plans. One resident with hemiplegia and hemiparesis following a stroke, and a BIMS score indicating moderate cognitive impairment, had a care plan intervention directing staff to keep the call light within reach and encourage its use. During observations, this resident was seen in bed after staff had set up breakfast, with the call button hanging over the upper left corner of the bedframe below mattress level and out of reach. Over an hour later, the call button remained in the same inaccessible position, and the resident reported not knowing where it was, stating that staff usually clipped it to the blanket but it might have moved when they sat him up for breakfast. A CNA who was not assigned to the resident confirmed the call button was out of reach and moved it to the tray table. Another resident with hemiplegia and hemiparesis following a stroke required total assistance with most ADLs, extensive assistance of two persons for bed mobility and transfers, and physical assistance for toileting. During observation, this resident was in bed talking on a cell phone while the call light was buried under linen on a chair, out of reach. The resident stated needing to be changed but having no way to call for help, and reported that this situation occurred frequently, leading the resident to call the main facility line and ask for the nursing supervisor for assistance. The resident reported having made such a call about 15 minutes earlier, and approximately 45 minutes later still had not received assistance. When informed, a CNA entered the room and confirmed the call light was not within reach and was located on a chair far from the resident. The DON and Administrator both stated their expectation that call lights be within residents’ reach at all times, and the facility’s written procedure required staff, when leaving a room, to ensure the call light is placed within the resident’s reach and to monitor call light location during rounds.
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