Failure to Ensure Resident Access to Light Switch Due to Broken Cord
Penalty
Summary
A deficiency occurred when a dependent resident with severely impaired cognition and recent stroke, who was bedbound, was unable to access the light switch in her room. The light switch was located behind the bed, approximately five feet from the floor and six feet from the bed, with a broken cord that was only three inches long. The resident reported she could not control the light and had to rely on staff for assistance, expressing frustration at repeatedly having to ask for help. She could not recall when the cord was broken. Observations confirmed the switch cord remained inaccessible, and both the Maintenance Director and a nurse acknowledged the issue. The Maintenance Director stated he conducted weekly walkthroughs and relied on staff to report repair needs, but did not notice the broken cord. The nurse providing care also did not notice the issue. The DON and Administrator both stated that staff were expected to be attentive to residents' environments and report repair needs promptly, but this did not occur in this instance.