F0558

D

Failure to Maintain Accessible Breath-Activated Call Light

Dover, Delaware Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The facility failed to ensure a resident’s specialized call light was consistently within reach and usable as care planned. The resident was admitted with schizophrenia and intellectual disabilities and had an admission MDS showing a BIMS score of 14/15, indicating intact cognition, but was dependent on staff for all ADLs. The care plan directed staff to keep the call light within reach and encourage its use for assistance, with prompt response to all requests. The resident used a breath-activated call light attached to a malleable black tube with a white end that needed to be positioned near her mouth to function. During one observation, the resident was in bed repeatedly calling out for help while the call light was positioned approximately six inches above her head, not in a position she could use.

Subsequent observations and interviews with staff confirmed that the call light was not consistently placed where the resident could activate it. A CNA stated the resident required total care and that the call light needed to be near her mouth to work, agreeing it was not in place. On another occasion, the resident again had the call light about six inches from her face and stated she could not use it. An LPN acknowledged the importance of the call light being within reach and had to repeatedly adjust and bend the device before the resident could successfully use it, after which the resident confirmed she could locate and use it. Nursing staff, including an RN and the DON, stated that the call light should always be within reach and that all staff working with the resident should know how to position it, but observations showed this was not consistently done, resulting in the resident at times being unable to use the call light when needed.