Inaccessible Call Systems for Multiple Cognitively Impaired, High-Fall-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents had access to a functioning call system from their beds and bathrooms/bathing areas, as required by facility policy. For three residents with severe cognitive impairment and documented fall risk, surveyors found that call systems were not within reach. One resident, an elderly female with lack of coordination, history of falling, and a care plan intervention specifying that the call system be within reach, was observed lying in bed without a call light. Instead, she had a bell attached to a bedside table that was placed across the room near a chest of drawers, out of her reach. Staff, including an RN and a CNA, acknowledged that the resident used the bell to contact staff, that she was unable to self-transfer and required staff assistance, and that staff should have placed the bedside table near her. The RN stated the resident had a history of yanking the call light cord out of the wall and destroying it. Two additional residents, both elderly males with severe cognitive impairment, muscle weakness or lack of coordination, unsteadiness on feet, and care plans identifying them as fall risks with interventions to keep call lights within reach, were also found without accessible call lights. One resident’s call light was observed on the floor behind the bed, and the other’s was hanging down from the head of the bed, both out of reach. A CNA observed that these residents often knocked the call lights off the bed and stated she would use a clip to secure them, acknowledging that call lights needed to be within reach so residents could call for assistance. The DON confirmed that all staff were responsible for ensuring call lights were within residents’ reach, and an LVN covering the hall also stated that call lights should be within reach so residents could call for help. The facility’s written policy required that each resident be provided with a means to call staff directly for assistance from the bed, toileting/bathing facilities, and from the floor.
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