F0558

E

Failure to Maintain Accessible Call Lights for Multiple Residents

El Paso, Texas Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that multiple residents had call lights within reach, despite care plans and staff statements indicating that call lights should always be accessible and used for assistance. For one male resident with a history of diabetes, multiple CVAs with left-sided paralysis, left below-knee amputation, mental illness, and significant ADL dependence, the care plan and bedside report instructed staff to encourage use of the call bell for assistance. Staff, including the social worker, LVNs, and CNAs, consistently reported that this resident was able to use the call light and that all staff were trained and responsible for keeping call lights within reach. However, during observation, the resident was in bed with the call light clipped to the head of the bed on his right side; he demonstrated difficulty reaching it due to limited right arm movement and inability to see where it was clipped, and he stated it was hard to reach at times.

Another female resident with Parkinson’s disease, dementia, impaired vision, bowel and bladder incontinence, and an ADL deficit had a care plan directing staff to anticipate and meet needs, ensure the call light was within reach, encourage its use, and respond promptly to requests. During observation while she was eating breakfast in bed, the call light was clipped to the pillowcase, slightly under the pillow, and not within her reach. The resident stated she used the call light for assistance and confirmed she could not reach it in its observed position, explaining that staff usually clipped it next to the side of the bed close to her arm. A medication aide who had administered medications earlier that morning acknowledged she had not noticed the call light was out of reach and then repositioned it. An LVN later stated she checked call lights during rounds but did not know who had served the breakfast tray.

A male resident with vascular dementia, depression, diabetes, frequent falls, impaired cognition, and incontinence had a care plan requiring that his call light be within reach and that he be encouraged to use it. During observation, he was lying in bed watching TV with the call light hanging on the wall plug-in plate by the head of the bed, not within his immediate reach, and he did not respond to the surveyor’s questions. A CNA stated this resident was oriented, ambulatory with a walker, able to use his call light, and that he did not like to use it and preferred to hang it on the wall, while also stating staff were trained to keep call lights within reach. The administrator also observed the call light hanging on the wall plate and reiterated that staff were trained to keep call lights within reach.

Another male resident with hypertensive heart disease, OCD, vascular dementia, multiple cerebral infarcts, orthostatic hypotension, repeated falls, and bowel and bladder incontinence had a care plan instructing staff to ensure the call light was within reach and to encourage its use. During observation, he was lying in bed awake with the call light hung on the wall plug-in plate by the head of the bed. He was alert and oriented to person and place and able to answer simple questions but did not answer when asked if he could use his call light. The administrator confirmed the call light’s placement on the wall plate. A CNA later stated this resident used his call light at times and that she normally checked call light placement at the start of her shift but had been late that day and had not checked. An LVN also stated the resident used his call light at times for assistance.

A further male resident with vascular dementia, diabetes, CVA with right hemiplegia, contracture of the right hand, impaired vision, and an ADL self-care deficit had a care plan noting his preference for the call light to be placed in bedside drawers and directing staff to ensure the call light was within reach and encourage its use. During observation, he was lying in bed watching TV, oriented to person and place, and the call light was hung on the wall plug-in plate by the head of the bed. He stated he was able to walk and did not use the call light for assistance. When an LVN entered with the surveyor, he observed the call light on the wall plate and then placed it within reach, while stating that staff were trained to keep call lights within reach and that he checked placement at the start of the shift and during rounds. The administrator later stated she had been informed by corporate staff that the facility did not have a policy on call lights.