Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a call light device was within reach for a resident, leading to a deficiency in accommodating the needs of the resident. The resident, a female with multiple diagnoses including dementia, chronic pain syndrome, and cognitive communication deficits, was observed on two separate occasions with the call light cord lying on the floor under her bed, out of reach. The resident was severely cognitively impaired, dependent on staff for all activities of daily living, and required a wheelchair for mobility. Staff interviews revealed that the resident was capable of using her hands and arms to activate the call light bulb if it was within reach. However, the call light was found on the floor, and staff confirmed that it should not have been left there, especially since the resident's room door was closed, preventing staff from hearing her if she called out. The Unit Manager stated that staff were expected to ensure call lights were within reach before leaving a resident's room, and that CNAs typically checked on bedbound residents every two hours. The facility's assessment emphasized person-centered care and prompt response to residents' requests, which was not adhered to in this instance.
Plan Of Correction
A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On resident number 52 call light was picked up and clipped to the resident bedsheet, so the bulb was within reach of the resident's. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. On Director of Nursing/designee completed an audit to ensure resident call lights are within reach. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By Director of Nursing/designee completed education with staff to ensure residents call lights are within reach of the resident. D) How will the corrective actions be monitored to ensure the practice will not recur; what quality measures will be put into place? a. Director of Nursing/designee to complete random audit to ensure resident call lights are within reach compliance with federal regulation F558 weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. b. Findings will be reported monthly at the QA/Risk management meeting until such a time substantial compliance has been determined.