F0558

D

Failure to Keep Call Light Within Reach for Dependent Resident

Houston, Texas Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident’s call light was within reach as required by the resident’s care plan and the facility’s call light policy. The resident was an older male with diagnoses including muscle wasting, abnormality of gait and mobility, difficulty in walking, and lack of coordination. His most recent Quarterly MDS showed a BIMS score of 4, use of a wheelchair for mobility, need for partial/moderate assistance with personal hygiene and upper body dressing, and always being incontinent of bowel and bladder. His care plan for fall risk, dated 02/05/2025, identified problems related to diabetes, neuropathy, and recurrent falls, with an intervention specifying that his call light must be within reach and that he required a prompt response to all requests for assistance.

On 02/06/2026 at 12:40 p.m., surveyors observed the resident lying in bed with his call light located between the bed rail and mattress, out of his reach. During this observation, the resident stated he wanted to call staff to request water but could not reach his call light, and that he usually could reach it but not at that time. In interviews, CNA A stated call lights should be within residents’ reach, that this resident needed the call light to request assistance, and that she checked call lights after providing care. The DON stated she expected all staff to check residents’ call lights when entering and before leaving rooms, to place call lights within reach, and to use clips to keep them attached to beds. LVN A similarly stated call lights should be within reach and that nurses and CNAs should have noticed and clipped the resident’s call light to his bed. The facility’s August 2021 Call Lights Policy required staff to place the call light within reach of the resident when leaving the room.