Failure to Ensure Call Light Accessibility and Prompt Response
Summary
The facility failed to ensure that patient call lights were accessible and answered promptly for two patients. For one patient with severe cognitive impairment, muscle weakness, and a history of traumatic brain injury, the call light was observed on the floor under the headboard, out of the patient's reach while the patient was lying in bed. This was confirmed by a registered nurse, who acknowledged that the call light was unreachable and that this could delay the patient's care needs. Facility policy requires that call lights be within reach and accessible to patients at all times. For another patient with a history of falls, reduced mobility, and a recent femur fracture, the call light was activated while the patient needed assistance with toileting. A certified nursing assistant walked past the room, saw the lit call light, but did not respond because the patient was not assigned to her that day. The CNA later confirmed she should have checked on the patient regardless of assignment. Facility policy states that any staff member who sees or hears an activated call light is responsible for responding. These failures had the potential to delay the provision of services and result in unmet patient needs.
Plan Of Correction
Measures that will be put into place to ensure that this deficiency does not recur. Beginning 3/11/2025, DSD initiated in-servicing for CNA and licensed nursing staff regarding ensuring call lights are in place and in reach of patients as well as ensuring that call lights are not passed in the hallway without answering. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur. Beginning 3/11/2025, DSDs will make weekly rounds of all patient rooms to ensure call lights are in place and within reach as well as that staff is not walking past call lights that are engaged in the hallways. These rounds will continue for 1 month or until substantial compliance is obtained. Any ongoing noncompliance will be reported by DSD at the monthly QA meeting. Date of corrective action would be completed: 04/03/25 C1115
Penalty
A resident with multiple medical conditions and a high risk for falls was found to have their call light placed under their pillow, making it inaccessible when assistance was needed. The care plan and facility policy required the call light to be within reach, but staff failed to ensure this, as confirmed by both DON and an LVN during interviews.
Call Light Not Accessible to High-Risk Resident
Penalty
Summary
The facility failed to ensure that a patient's call light was within reach, as required by both facility policy and the patient's care plan. During an observation, the call light for a patient with multiple medical conditions, including respiratory failure, COPD, pleural effusion, and a history of falls, was found under the patient's pillow and not accessible. The patient reported being unable to locate or reach the call light when needing to call for assistance. The patient's care plan specifically indicated that the call light should be within reach and that the patient should be encouraged to use it for assistance. Interviews with the Director of Nursing and a Licensed Vocational Nurse confirmed that the call light should always be accessible to patients to ensure their safety and timely care. Both staff members acknowledged that failure to provide access to the call light could delay care and increase the risk of falls. Review of facility policies further supported the requirement for call lights to be within reach before staff leave a patient's room. The deficiency was identified for a patient assessed as high risk for falls, with documented cognitive impairment and dependence on staff for several activities of daily living.
Plan Of Correction
C1115 Nursing Service--Patient Care How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 9/24/25, patients 6's call light was immediately placed within reach. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - On 9/24/25, the Director of Staff Development (DSD) conducted facility-wide rounds to verify proper placement of call lights. - No other residents were affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - On 9/24/25, and 10/14/25, the DSD conducted in-service training for all staff on the proper use and placement of call lights, emphasizing the importance of ensuring that call lights are always within the resident's reach. - Starting 10/10/25, the DSD will conduct random checks of call light placement 5x/week reviewing 5 residents each day, for a duration of three months. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The DSD will be reporting the results of the monitoring to the QA committee monthly x 3 months for review and recommendations and ensure substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and action plan to prevent any further deficient practices.
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