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 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.
A resident with quadriplegia, intact cognition, depression, low BMI, and a stage 4 sacral pressure ulcer required assistance with all ADLs but repeatedly did not have an accessible call light. Surveyors observed the call bell placed between the bed and side rail and later on a dresser, both out of the resident’s reach. The resident reported being unable to use the call system and sometimes relying on a roommate to call for help, and stated they would not have been able to summon assistance over a weekend if needed. A hospice RN noted that although the call bell was placed within reach during her visit, she did not believe the resident could effectively use it, and the administrator later confirmed the call bell was not within reach.
Failed Room and Bathroom Call Light Functionality: Two residents had nonworking light/call equipment. One resident with intact cognition reported the wall light by the bed did not work, and surveyors observed the light was missing the pull cord and switch. Another resident with moderately impaired cognition had a bathroom emergency call light that did not activate the call system when pulled, and staff confirmed it was not working.
Call Light Not Kept Within Reach: A resident with Parkinson's disease, osteoarthritis, and unsteady gait was observed sitting in a wheelchair with the call light placed in the bed under the covers and out of reach. The resident stated he needed help getting back into bed but could not reach the call light. A PT and the DON confirmed the resident required assistance and that the call light should have been within reach.
Call Light Not Kept Within Resident Reach: A resident with CVA-related hemiplegia, intact cognition, and dependence for toileting hygiene and transfers had a care plan directing that the call light remain within reach. During repeated observations, the call bell was found tucked between the mattress and bedframe, on the floor, and hanging off the side of the bed, leaving it out of reach while the resident called out for staff and requested assistance. An LPN, ADM, and DON acknowledged the call bell should have been within reach.
Improperly Fitting Protective Helmet: A resident with a hx of TBI, SAH, schizoaffective d/o, and severe cognitive impairment was supposed to wear a protective helmet when out of bed, but was repeatedly observed without it. When staff placed the helmet on him, he said it was too big and covered his eyes; the DON confirmed it did not fit properly and had not fitted him for the helmet.
Surveyors found that staff failed to keep call lights within reach for two residents whose care plans required accessible call systems. One resident with moderate cognitive impairment and multiple conditions, including osteoarthritis and prior cerebral infarction, was observed with her call light on the floor, out of reach, despite being able to use it. Another resident with severe cognitive impairment, mobility issues, and diabetic polyneuropathy was observed in a geri-chair with the call light rolled up on a bedside table, also out of reach, even though she could use it to request help. Staff, including a CNA, a supervisor, and the DON, confirmed that both residents were capable of using their call lights and that facility policy requires call lights to be easily reachable at all times.
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