Call Lights Not Kept Within Reach: Two residents with care plans requiring call lights to be within reach were observed with their call lights clipped to the curtain, the outer edge of the bed, the side of the mattress, at head level, or hanging under the bed, all out of reach. One resident with severe cognitive impairment said she could not find her call light and that it was usually not within reach, while the other resident with dementia and hemiplegia stated she could not reach or find hers. Staff confirmed the call lights were not within reach.
A resident with severe cognitive impairment, aphasia, and other diagnoses had a soft touch call light repeatedly observed draped on the bed rail and out of sight and reach while he was in bed. The care plan included using the bell to call for assistance, and an LPN/TXN stated the device should have been within reach because the resident was physically capable of using it.
Call Lights Not Kept Within Residents’ Reach: Two residents had call lights repeatedly found on the floor, under the bed, or wrapped around the bed’s positioning bar and out of reach. One resident was cognitively intact and stated the call light was often out of reach, while staff including CNAs, an LPN, and the DON confirmed the call lights should have been within reach.
Call lights were left out of reach for two residents whose care plans required them to be kept within reach. One resident with hemiplegia, weakness, and a healing R humerus fracture had her call light found in a laundry basket, while another resident with CHF, weakness, and a R BKA had her call light hanging below the side rail and later near the floor. Both residents stated they used their call lights for staff assistance, and staff confirmed the call lights were not reachable.
Call Light Left Out of Reach: A resident with generalized muscle weakness, difficulty walking, hemiplegia/hemiparesis, and moderate cognitive impairment was observed in bed with her soft touch call light placed on the nightstand and out of reach. She stated she needed assistance to be changed and could not reach the call light, and an LPN confirmed it was not within reach. The resident's care plan included keeping the call light within reach.
Surveyors found that the facility failed to ensure call lights were accessible and appropriate for several residents, including one with hemiplegia, aphasia, functional quadriplegia, and severe cognitive impairment who could not operate a standard call bell and did not have an adapted device in place. Observations on multiple occasions showed call lights wrapped around bed rails, wedged between the mattress and rail, lying on the floor at the foot of the bed, placed on top of a mini fridge, or hanging on the wall, all out of residents’ reach. Staff, including CNAs, LPNs, the DON, and a corporate RN, acknowledged that call lights were not within reach despite care plans identifying fall risk and specifying that call lights should be kept within reach.
A resident with CVA-related hemiplegia, diabetes, cardiomyopathy, and AFib was observed in bed and later in a geri-chair with the call light out of reach because the cord was too short. The resident said he could not reach it most of the time and had to holler for help. An LPN and the DON confirmed the call light was not within reach, despite the care plan and facility policy requiring it to be placed within reach.
A resident with paraplegia, severe cognitive impairment (BIMS 6), and dependence for mobility and hygiene was repeatedly observed in bed and in a Geri chair without access to a call light, despite facility policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. On multiple occasions throughout the day, the call light was found on the floor or hanging on the side of the bed, out of the resident’s reach. The resident reported being unable to reach the call light, and both a CNA and the DON acknowledged that the call light was not within reach and should have been accessible.
A resident with severe cognitive impairment and no functional impairment to the upper or lower extremities was observed in bed with the call light on the floor and out of reach on more than one occasion. Staff confirmed the call light should have been within the resident’s reach, and the roommate reported calling for help when the resident yelled out.
A resident with bilateral hearing loss, paraplegia, and moderately impaired cognition was not provided with an alternate means of communication despite a care plan noting use of a communication board and tablet. During observations, no communication board or tablet was at the bedside, and interviews with the resident, family, and staff confirmed the resident relied on ASL and video calls to have needs relayed to the facility, including requests for pain medication.
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