Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A resident with functional quadriplegia and unspecified dementia was readmitted to the facility and had documented limitations in the range of motion in both upper extremities. The resident's care plan specified that the call light device should be within easy reach to allow the resident to request assistance for activities of daily living and hygienic needs. However, during multiple observations, the call light device was found to be inaccessible: once it had fallen between the bed mattress and the upper left side rail, and another time it was pinned to the upper right side of the resident's pillow, still out of the resident's reach. Interviews with staff, including the DON and LVNs, confirmed that the resident could not access the call light device and would be unable to contact staff for help when needed. The facility's policy required that the call light be accessible to residents when in bed or wheelchair, but this was not followed in the resident's case. The deficiency was identified through direct observation, staff interviews, and review of the resident's care plan and facility policy.