Call Lights Not Kept Within Reach of Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that call lights were accessible to residents who required a means to request assistance, as required by their care plans and facility expectations. For one resident with dementia, impaired cognition, and osteoarthritis, the care plan included interventions to provide a safe environment by keeping the call light within reach and encouraging its use for assistance. During an observation, this resident was found lying in bed with the call light wrapped and hooked onto the wall behind the headboard, away from the door and out of her reach. When asked, the resident attempted to reach over her shoulder but could not touch the call light and did not know how long it had been in that position. A medication aide stated that the resident used her call light, that it was supposed to be within reach and clipped to the bed, and that staff were expected to check call lights during two-hour rounds and while passing medications. The aide acknowledged having seen the call light hooked on the wall earlier that morning and had not yet repositioned it because she was providing care to another resident. Another resident with a neurocognitive disorder with Lewy bodies, lack of coordination, and anxiety disorder had a care plan that directed staff to encourage the resident to use the bell to call for assistance and to have an agreed-on method, such as a call light or bell, to relieve anxiety. This resident was observed asleep in bed with the call light lying under the bed against the wall, out of reach. The resident could not be roused sufficiently to follow directions or demonstrate whether she could reach the call light. Two CNAs later stated that this resident did not use her call light but acknowledged that, despite this, the call light was supposed to be within the resident’s reach. One CNA picked up the call light from the floor and clipped it to the bed, confirming that it had been out of reach at the time of the observation. A third resident with cerebral palsy, severe intellectual disabilities, lack of coordination, and non-verbal communication had a care plan intervention to ensure a safe environment by keeping the call light within reach. During an observation, this resident was initially asleep and later awake but non-verbal. The call light in this room was found wrapped and hooked onto the wall toward the center of the room, past the footboard, and out of the resident’s reach. An LPN stated she did not know why the call light was hooked on the wall and that she had not had a chance to check the room earlier that morning. She reported that the resident normally did not or could not use the call light, but that it was usually clipped to the bed, and that housekeeping, night shift, or others could have placed it on the wall. The DON and the administrator both stated that their expectation was for call lights to be within reach of residents and acknowledged that call lights out of reach could result in residents’ needs not being addressed in a timely manner. The facility’s fall policy also specified that call bells should be positioned within reach as part of environmental fall prevention measures.
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