Call Light Not Kept Within Reach for Resident With Limited Mobility
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was kept within reach as required by policy. During observation on 12/2/25 at 10:46 AM, a resident who was alert and oriented x3, able to verbalize needs, and had limited upper extremity mobility was found lying in bed attempting, but struggling, to reach a call light that was tangled between the bed siderail and mattress. The resident stated he was trying to reach the call light to call for his nurse or CNA. When the surveyor notified the assigned RN at 10:50 AM and showed her the situation, the RN acknowledged she had administered the resident’s medications that morning and had forgotten to ensure the call light was accessible. The RN then had to lift the mattress to remove the tangled call light. Later that day, the DON confirmed that residents’ call lights should be within reach and accessible at all times, consistent with the facility’s call light policy revised on 6/30/25, which states that call lights must be placed within reach of residents who are able to use them at all times. This sequence of events demonstrates that the resident’s needs and preferences for accessible communication with staff were not reasonably accommodated when staff failed to position the call light within the resident’s reach after providing care, resulting in the resident being unable to independently summon assistance.
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