Call Light System Not Accessible to Dependent Residents
Penalty
Summary
Surveyors observed that the facility failed to ensure that the call light system was within reach for two residents who were dependent on staff for activities of daily living. In one instance, a resident with cerebral palsy, who was cognitively intact but fully dependent for mobility and self-care, was found lying in bed without the call light within reach; it was instead hanging on a feeding tube pole. A Certified Nursing Assistant confirmed that the call light was not accessible to the resident and acknowledged it should not have been placed on the feeding tube pole. The Director of Nursing also confirmed that the resident was dependent on staff and that the call light should always be within reach. In another case, a resident with hemiplegia and hemiparesis, and moderate cognitive impairment, was observed lying in bed with the call light clipped to the privacy curtains, out of reach. A Registered Nurse confirmed the call light was not accessible and stated it should not have been placed on the curtains. Both residents' clinical records indicated they were dependent on staff for all activities of daily living, including mobility and personal care. The facility's policy required that each resident have a means to call staff for assistance from their bed, but this was not followed in these instances.