Failure to Keep Call Lights Within Reach as Care Planned
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure residents’ call lights were kept within reach as required by individualized care plans, thereby limiting residents’ ability to summon assistance. During a tour of the Homestead unit, multiple residents were observed in bed or sitting on the edge of the bed with their call bells on the floor, behind the bed, or wrapped around or under the bed frame. One resident’s call bell was found on the floor behind the bed on two separate observations, and the resident stated that staff had taken the call bell away. Another resident’s call bell was repeatedly observed hanging under the bed frame and dragging on the floor. A third resident, who reported using the call button to call the nurse, had the call bell lying on the floor behind the bed. A fourth resident, sitting on the edge of the bed, had the call bell on the floor behind the bed and reported that when the call bell was used, staff came in, turned it off, and did not return. Review of the residents’ care plans showed that several had documented ADL self-care performance deficits related to conditions such as decreased mobility, dementia, encephalopathy, schizophrenia, and poor safety awareness, with specific interventions directing staff to encourage use of the call bell and to ensure the call light was within reach, with prompt response to all requests for assistance. These care plans, initiated on various dates, consistently required that call lights be accessible to residents at risk for falls and with mobility or cognitive impairments. Despite these documented interventions, staff did not maintain the call bells within reach for at least seven residents on the Homestead unit. When a staff member was shown a call bell on the floor, the staff member acknowledged the need for a clip to secure the cord to the sheet and stated that the situation with call bells was a known problem. The DON and Nursing Home Administrator were later informed of these concerns.
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