Resident Unable to Access Call Light Due to Improper Placement
Penalty
Summary
A deficiency was identified when a resident with significant physical and cognitive impairments did not have access to a functioning call light system. During an observation, the resident was found asleep in bed with an air mattress and enteral feeding in progress. The tap button call light, designed for residents with limited finger strength, was hanging from the left handrail, three inches above the floor, and not within the resident's reach. The resident's medical history included left hemiplegia and hemiparesis following a cerebral infarction, dysphagia, generalized muscle weakness, gastrostomy status, and aphasia. The Minimum Data Set assessment indicated severe cognitive impairment. The resident's care plan specifically noted a high risk for falls and injuries, with interventions requiring the call light to be within reach and encouragement to use it for assistance as needed. Interviews with facility staff, including a CNA, LVN, and the DON, confirmed that the call light should have been within the resident's reach, especially given the resident's mobility limitations. Staff acknowledged that the resident would not be able to call for help if the call light was not accessible. Facility policies and job descriptions reviewed also required staff to ensure call lights were within easy reach of residents, particularly those with mobility issues.