F0558

D

Failure to Keep Call Lights Within Reach for Dependent Residents

Richland Hills, Texas Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring that call lights were accessible to two residents. For one male resident with a history of falls and rib fracture, the Quarterly MDS showed severe cognitive impairment (BIMS score 00) and a need for assistance with transfer, bed mobility, toileting hygiene, showering, dressing, and personal hygiene. His comprehensive care plan identified risk for falls and communication problems, with an intervention to ensure the call light was within reach. During observation, he was awake in his wheelchair, and his call light was found on top of his bed with the cord positioned between his and his roommate’s bed frames; when asked about the call light, he shook his head, indicating he did not know where it was.

A female resident with epilepsy, muscle weakness, lack of coordination, repeated falls, and difficulty walking was also identified as having severe cognitive impairment (BIMS score 00) and needing assistance with transfer, bed mobility, toileting hygiene, showering, dressing, and personal hygiene. Her comprehensive care plan documented fall risk and included an intervention to keep the call light within reach. During observation, she was awake in bed, and her call light was found on the floor; when asked where her call light was, she shrugged her shoulders, indicating she did not know its location.

Staff interviews confirmed expectations that call lights should always be within residents’ reach so they can call staff when they need something or need assistance. A CNA stated that call lights are for all residents, dependent or independent, and acknowledged responsibility for ensuring call lights are within reach for assigned residents, noting she should have verified the call light’s placement after making a bed. The DON stated that nurses and CNAs are responsible for ensuring call lights are within reach and acknowledged the importance of call lights for residents to call staff, but also commented that a resident might not need the call light while sleeping and that an alert, communicative resident might not have a problem if the call light was on the floor. The Administrator stated that call lights should be within reach at all times and monitored throughout the day, and also reported that the facility did not have a policy specifically addressing call lights being within reach.