Call lights were not kept within reach for five residents reviewed for residents' rights. Residents with diagnoses including bipolar disorder, stroke, TBI, Alzheimer's disease, schizophrenia, PTSD, diabetes, schizoaffective disorder, OCD, and unsteadiness on feet were observed with call lights placed under beds, hung on wall hooks out of reach, or coiled and pinned so they could not independently access them. An LPN and the DON stated the call lights should have been within the residents' reach.
A facility failed to ensure call light access was within reach in 2 shower stalls. Observations found the 100 Hallway and 400 Hallway shower stalls had call light boxes mounted high without call light strings, leaving them out of reach for a resident using the stall. The CRN stated the showers should have accessible call light strings for residents and staff assisting in the shower stall.
Call Light Out of Reach: A resident with acute cystitis with hematuria, DM, and cirrhosis was found sitting in a chair with the call light hanging on the wall and out of reach. The resident asked a surveyor to call staff, and later an RN and CNA entered the room after being notified. The CNA stated the resident could not reach the call light, which was on the other side of the bed and should have been within reach.
Call Light Not Within Reach: A resident with a displaced trimalleolar fracture, MDD, and diabetes was observed sitting in a recliner with the call light cord hanging down the wall and under the bed, out of reach. The resident could not independently reach the call light, and the DON stated the call light should have been within reach but had not been.
Resident's Drinking Water Was Not Within Reach: A resident with quadriplegia and DM was observed in bed with drinking water placed on a bedside table out of reach on multiple occasions. A CNA later acknowledged the water was not reachable, moved an overbed table closer, and placed the water directly in front of the resident so it could be reached.
A resident with chronic kidney disease and chronic atrial fibrillation was observed lying in bed with the call light plugged into the wall and hanging under the head of the bed, out of reach, and the resident could not independently access it. An RN and the RCN each acknowledged that the call light should have been within the resident’s reach and that it was not, resulting in a failure to reasonably accommodate the resident’s needs and preferences.
Surveyors found that staff failed to keep call lights within reach for two residents, contrary to facility policy requiring accessible call lights to ensure timely responses to needs. One resident with COPD and dementia was in bed with the call light hanging under the foot of the bed, out of reach. Another resident with a lumbar fracture and history of repeated falls was seated in a recliner while the call light was draped over an overbed table pushed against the bed on the opposite side of the room, also out of reach. A CNA and the RNC both acknowledged that call lights should have been within reach and were not in these cases.
A resident with dementia, cognitive communication deficit, history of TIA, and adult failure to thrive, and a severely impaired BIMS score, was found soiled with stool leaking from her incontinence brief and was unable to state how long she had been in that condition. Although documentation indicated she used her call light appropriately, surveyors observed that she did not activate the push-button call light when prompted and only smiled in response, even when a CNA asked her to demonstrate its use without pointing to it. The facility failed to provide an appropriate adaptive call light despite the resident’s inability to effectively use the standard device, resulting in a lack of reasonable accommodation of her needs and preferences.
The facility did not follow its call light policy requiring call systems to be within residents' reach. One resident with psychosis and muscle weakness was observed eating at a side table while the call light was tied to a nightstand drawer behind her, out of reach, which a CNA acknowledged was improper. Another resident with hemiplegia and diabetes was found reclining in bed with the call light placed on a bedside table he could not reach after staff provided care, and a CNA confirmed it should have been positioned within his reach. The CNO also stated that call lights are expected to be within residents' reach and were not in these cases.
Surveyors found that staff did not follow the facility’s call light accessibility policy for a resident with hemiplegia and diabetes. The resident was observed reclining in bed with the call light pinned to the headwall cord and not within reach. An RN and the RSN both acknowledged that call lights are required to be within residents’ reach and that this had not occurred in this case.
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