F0677

E

Failure to Provide Timely ADL Assistance and Maintain Functional Call Light Access

Redford, Michigan Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely assistance with activities of daily living (ADLs), positioning, and access to call systems for multiple dependent residents. One resident with multiple sclerosis, lower leg contractures, malnutrition, and documented dependence on staff for all hygiene, toileting, dressing, bed mobility, and transfers was repeatedly observed lying in bed in the same position over extended periods on consecutive days. The resident’s legs were contracted with heels at the buttocks, knees pointed to one side, and the torso twisted, with visible gauze dressings on both feet and the right hip showing bloody drainage soaked through in several areas. No pillows or devices were in place to pad bony prominences or separate the legs and feet, and no specialty or low air loss mattress was in use despite care plan directions to reposition frequently and use a concave mattress. The call light was either under the covers or hanging over the headboard, out of the resident’s reach, while the responsible party reported multiple open pressure-related wounds on heels, sides of feet, hips, and buttocks.

Another resident with Alzheimer’s disease, heart disease, chronic pain, and a care plan indicating dependence or supervision for ADLs and bed mobility was observed in bed with the head of the bed elevated but positioned so that their waist was beyond the bed’s break. The bed controller was hooked on the head of the bed and not readily usable, and the resident was unable to reach the call light placed at the shoulder or under the blankets. Over several observations in one day, the resident remained in bed with limited ability to adjust their own position and without clear access to the call system. A third resident with stroke, heart failure, dysphagia, and care plan needs for substantial assistance with bed mobility and dressing was observed pressing the call light multiple times without staff response during the interaction, reporting that the call lights were not working. Later, this resident was seen in a wheelchair in a hallway corner, slid down with buttocks at the edge of the chair and shoulders at the top of the low back, unable to lock both wheelchair brakes or reposition independently, and stating they needed help while nearby staff were occupied elsewhere. The same resident was later observed in bed with feet on the floor and the backs of the knees at the edge of the bed, still dependent on staff for ADLs.

A resident with traumatic brain injury, epilepsy, anxiety, and a care plan indicating dependence on staff for most ADLs reported not being changed in a timely manner after waking early and requesting assistance, and also reported shoulder pain for which the facility did not consistently do anything. This resident’s call light cord was looped over the wall junction box, and a bell on the tray table did not ring reliably when tested, with no immediate staff response. Another resident with dementia and diabetes, dependent for toileting and needing substantial or partial assistance for other ADLs, was observed in bed without pants, with the call light looped over a wall box across the room from the bed and no secondary bell visible. The resident reported missed scheduled showers, difficulty getting staff to assist after incontinence episodes, and described being left in a wet brief that eventually soaked through to their pants before staff removed it. A urinal partially filled with urine was hanging inside a trash can, and the resident stated they did not always feel the need to void and had accidents.

Across these residents, the call light system itself was found to be nonfunctional as an effective alert mechanism. Multiple residents reported or demonstrated that call lights did not work properly, and clocks in at least two rooms were not running. The LPN assigned to the unit stated that only one nurse was assigned to care for 17 to 24 patients and that the call light system had not worked properly for more than six months, with no audible tone and the monitor located inside the nurse’s office on top of a desk. During observation, activated call lights showed on the monitor, including one that had been on for 20 minutes, but there were no lights above the doors and no audible chime. The facility’s call light policy addressed prompt answering of call lights but did not address ensuring the functionality of the call light system. These conditions resulted in residents who were dependent on staff for ADLs, positioning, toileting, and safety being unable to reliably summon assistance or receive timely care.