Inaccessible Call Light for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident’s call system was accessible at the bedside as required by the resident’s care plan. A female resident with a history of stroke, diabetes, and hypertension was dependent on staff for ADLs including dressing, hygiene, toileting, bathing, positioning, and transfers, and was assessed as moderately impaired in daily decision making. Her comprehensive care plan, last reviewed on 12/23/25, identified her as at high risk for falls related to gait and balance problems and included an intervention to keep the call light within reach and encourage her to use it for assistance as needed. On observation, the resident was lying in bed with positioning rails on both sides, and her call button was found on the floor below the bed, out of her reach. The resident reported that she used the call button to obtain staff assistance but could not reach it and was dependent on staff. A CNA stated that the call button must have fallen off the bed and acknowledged it should be within the resident’s reach, then wrapped the call button cord around the right positioning rail so it was accessible. The DON stated she expected residents’ call devices to be within reach while in bed and confirmed that this resident used her call light for assistance. The Administrator reported that the facility did not have a policy for call lights.
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