Resident call light left out of reach. During observation rounds, a resident’s call light was found on the floor behind the head of the bed. An LPN picked it up and placed it near the resident, and stated that the aide should have ensured the call light was within reach after morning care.
Call Bell Not Within Reach: A resident with quadriplegia, a communication deficit, and contracted hands and torso was observed in a geri-chair with the call bell placed on the bed and out of reach. The resident could not answer when asked if the bell could be reached, and a GNA stated the resident could not use the call bell and that it did not matter if it was near them, despite the care plan directing staff to keep the call bell within easy reach. The DON confirmed that all residents are expected to have access to a call bell.
Call lights were not kept within reach for multiple residents. Surveyors observed two residents with call bells out of reach or hidden, and both were dependent on staff and unable to reach them. In another room, a resident was found in bed with the call light on the floor while reporting pain and waiting for medication; an LPN confirmed the call light should have been within reach.
Non-functioning resident call bells were identified in multiple rooms after residents reported delayed staff response and repeated failures of the call system. A resident stated the call light sometimes did not work and testing showed no activation at the room unit, hallway dome, or nurse station, while other residents reported call bells that had not worked for weeks and said they sometimes had to seek staff in the hallway or rely on family to call the facility. Staff confirmed ongoing call system problems in several rooms, and testing showed no staff response to some activated call bells.
Inaccessible Resident Call Bell: A resident was observed in pain, but the call bell was not within reach and could not be located. The surveyor had to use the empty bed call bell to get staff assistance, and an RN later found the resident's call bell behind the head of the bed.
A resident reported to a surveyor that the call system in their room was not working after pressing the call button and receiving no response. The surveyor observed that pressing the call button did not activate the call light above the door or the call station at the nurses’ station. An LPN confirmed that the system should provide visual hallway lights, an audible alert, and display the room number at the call station when used, but testing showed the call system in that room was not functioning properly.
A resident who was alert and oriented, non-verbal except for mouthing words, and had right-sided weakness and a trach stoma with O2 humidification was observed in a wheelchair with the call bell tucked inside the nightstand drawer and out of reach. An LPN confirmed the call bell had been placed there and acknowledged the resident would not be able to call for help if unable to reach it; the DON stated staff are expected to keep call bells within reach.
Surveyors identified that two residents did not have accessible call light cords in their room, as the cords were found tied and curled on the floor against the wall, despite both residents being alert and ambulatory. In a separate case, a resident reported intermittent problems with a call light that, when tested by the resident, a GNA, and later the NHA, failed to illuminate in the room or hallway on two separate occasions, with staff attributing the issue to a loose wall adapter.
A resident’s call bell was found on the floor under the bed and was not within reach when the resident requested help with a nasal cannula. A GNA later retrieved the call bell and stated it had previously been placed on the bed, but it was not clipped and the resident was seated in a wheelchair next to the bed. The DON acknowledged the concern.
Broken Resident Call Lights: The facility failed to ensure working call systems were available for two residents’ bathroom and bathing areas. A resident reported that the call light was not working, and staff confirmed that both that resident’s and another resident’s call lights were not functioning. The DON was notified, and the Administrator later acknowledged the broken call light concern.
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