Failure to Provide Accessible Call Light System for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with left body hemiplegia and right-sided weakness was unable to use the standard call light system in their room. Observations showed the call light was placed near the resident's left hand, but the resident was unable to press the button due to limited finger movement. The resident was dependent on staff for most activities of daily living and had impaired cognitive skills, as documented in their medical records and assessments. Despite these limitations, the call light system provided was not accessible to the resident. Interviews with staff revealed that the certified nursing assistant (CNA) was aware the resident could not use the call light but did not notify the charge nurse or maintenance to obtain an alternative system, such as a touch pad call light. The facility's policy required staff to assess residents' ability to use the call system and to provide alternatives if needed, but this was not followed. The director of staff development and a registered nurse both confirmed the importance of ensuring residents can use their call lights, but in this case, the necessary accommodations were not made.