A resident with paraplegia and bilateral above-the-knee amputations was observed in bed with his call light on the floor and out of reach on multiple occasions. He was alert and oriented, able to use the call light, and stated he could not reach it to ask for help with his menu, nasal cannula, or breakfast. Staff confirmed the call light should have been within his reach, and the facility policy required call lights to remain within reach for residents able to use them.
Call Light Not Kept Within Reach: A resident with Alzheimer's disease, Parkinson's disease, dementia, repeated falls, and moderately impaired cognition was observed in bed on multiple occasions with her call light placed on or draped over the nightstand and not within reach. Her care plan directed that the call light be kept within reach, and staff interviews confirmed it should have been accessible to her.
A resident’s paid local TV channels were glitchy and unusable, with flickering, frozen images, and strange colors. He reported the problem to the maintenance supervisor, but staff had not promptly resolved it, and administrative staff were unaware of the issue. The facility policy stated resident complaints must be addressed promptly.
A resident with pain, hx of falls, overactive bladder, severely impaired cognition, limited BLE ROM, and dependence for toileting, bathing, and transfers had a care plan directing staff to keep the call light within reach. During observation, the resident was sitting in a high-back wheelchair watching TV, but the call light was pinned to the wall out of reach. Staff interviews confirmed call lights should be within the resident's reach when in the room.
A resident with PTSD, vascular dementia, and DM had a BIMS score of 3 and required assistance with ADLs. He was observed sitting in his chair with his bedside table in front of him and was unable to find his call light, stating he did not know where it was. Staff stated the call light should be clipped to the chair or otherwise kept within reach, and the care plan directed staff to ensure the call light was within reach and respond promptly to requests for assistance.
A resident with COPD, major depressive disorder, neuromuscular dysfunction of the bladder, and DM had intact cognition but needed extensive ADL assistance and had lower-body impairment. His care plan directed staff to keep his call light within reach, yet during observation it was found at the bottom of the bed and out of reach while he was lying in bed. Staff stated call lights should always be within the resident's reach and that residents should be told where they were placed.
A facility failed to keep call lights within reach for two residents with significant cognitive and physical impairments. One resident with hemiparesis, vascular dementia, and Parkinson’s disease was observed in a Broda chair while his soft-touch call light was placed out of reach, and he was unable to access it. Another resident with aphasia, a G-tube, CVA, severely impaired cognition, and dependence for all ADLs had her call light hanging behind the bed and out of reach. Staff stated call lights should always be within residents’ reach.
A resident with C-diff and CHF, newly admitted and with a baseline care plan that did not address call light use, was repeatedly found without access to a call light. Surveyors observed the resident yelling for help with her room door closed and later noted the call light on the floor under the bed and again on the floor while the resident sat in a recliner and stated she wanted to return to bed but could not do so independently. Staff reported using a binder clip to attach the call light to the resident’s clothing because the cord lacked a clip, acknowledged the resident sometimes threw the call light to the floor, and stated that call lights should be kept within residents’ reach. An administrative nurse confirmed the expectation that call lights be accessible at all times and was unsure about the use of a binder clip, and no facility policy on call lights was provided.
Call Light Not Kept Within Reach: A resident with CVA, cognitive communication deficit, and dysphagia was dependent on staff for multiple ADLs and had a care plan directing that her call light be kept within reach. During observations, the call light was found on the floor behind furniture and out of reach while she was in bed, and an CMA stated she should always have it within reach.
A resident with Alzheimer’s disease, severely impaired cognition (BIMS 0), and total dependence for ADLs had a history of falls and a care plan requiring the call light to be kept within reach due to fall risk and poor safety awareness. During observation, the resident was in bed, awake and yelling out, while the call light was located behind the bed’s headboard and not accessible. Staff, including a CMA, an LN, and an administrative nurse, acknowledged that call lights should be within residents’ reach, and facility policy required staff to ensure call lights were reachable and answered promptly, but this was not done for this resident.
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