Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's call light was within reach while the resident was lying in bed. The resident, who had severe cognitive impairment, legal blindness, and bilateral leg amputations, was assessed as being dependent for all hygiene, dressing, and transfer needs, and required a mechanical lift for transfers. The resident's care plan specifically included the intervention to ensure the call light was within reach to provide a safe environment. On the day of the incident, the call light was observed looped over and behind the bed frame, out of the resident's reach. When asked if he could use the call light, the resident, who could only answer in one-word responses, attempted to find it by moving his hand on the bed but was unable to locate it. An LVN acknowledged that the call light had been moved during care and was not returned to the resident's reach. Both the LVN and the Regional Compliance Nurse confirmed that the resident would not be able to call for help without the call light in reach. It was also noted that the facility did not have a policy on call lights.