F0558

D

Failure to Keep Call Light Within Reach for Dependent Resident

Emporia, Kansas Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences by not ensuring the resident’s call light was within reach. The facility had a census of 51 residents with a sample of 14, including one resident with diagnoses of hypertension, dementia, unsteadiness on feet, muscle weakness, and repeated falls. The admission MDS documented a BIMS score of four, indicating severely impaired cognition, and showed the resident was dependent on staff for toileting and required supervision or touching assistance with eating. A Falls CAA identified the resident as at risk for falls due to a history of falls, impaired mobility, weakness, dementia, a urinary catheter, and the need for assistance with transfers and mobility. The care plan documented that the resident had been instructed to use the call light for assistance and was dependent on one or two staff for toileting throughout the day to manage bowel incontinence.

During observation, the resident was seen sitting in a Broda chair in his room with the TV on, while his pancake call light was lying in the middle of his bed, out of his reach, preventing him from calling for assistance. A CNA confirmed at the time of observation that the call light was out of reach and stated it should be placed where the resident could reach and use it, then moved the call light to the bedside table within reach. Subsequent interviews with an LN and an administrative nurse confirmed that residents’ call lights should always be within reach and that it was every staff member’s duty to ensure this. The facility’s Call Light System policy documented that a call button or pull cord would be located next to each bed and in each resident’s bathroom, underscoring that the observed placement of the call light did not comply with facility expectations and practice.