Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ call lights were within reach as required by facility policy and individual care plans. The facility’s policy on the Resident Call Light System, revised 06/2023, states that staff must ensure the call light is easily reachable by the resident. Resident #2, admitted with multiple diagnoses including bilateral primary osteoarthritis of the hip, mild neurocognitive disorder with behavioral disturbance, vertebral compression fractures, intellectual disabilities, schizophrenia, and cerebral infarction, had an MDS BIMS score of 11, indicating moderate cognitive impairment. Her care plan specified that she was to have a working and reachable call light and be encouraged to use it for assistance as needed. On 01/12/2026 at 9:40 a.m., surveyors observed Resident #2’s call light on the floor and not within her reach. During an interview at 9:50 a.m., S13CNA confirmed that Resident #2 was able to use the call light and that it was not within her reach. Resident #51, admitted with diagnoses including difficulty in walking, other lack of coordination, primary generalized osteoarthritis, type 2 diabetes mellitus with diabetic polyneuropathy, and muscle wasting and atrophy, had an MDS BIMS score of 7, indicating severe cognitive impairment. Her care plan documented that she required staff assistance with ADLs, was to have a working, reachable call light, and was to be encouraged to use the call light for assistance. On 01/12/2026 at 9:01 a.m., surveyors observed Resident #51 sitting in a geri-chair with her call light rolled up on the bedside table, not within her reach. At 9:20 a.m., S12SUP confirmed that the call light was not within the resident’s reach, stated it should have been, and confirmed that Resident #51 was capable of using the call light to call for assistance. On 01/14/2026 at 10:25 a.m., S2DON acknowledged awareness that the call lights for both residents had been found out of reach and stated that the facility’s process is for staff to place call lights within residents’ reach before exiting the room and to ensure call lights are within reach at all times.
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