Failure to Provide Accessible Call Light for Resident with Quadriplegia
Penalty
Summary
A resident with quadriplegia and multiple complex medical conditions, including neuromuscular dysfunction, stage 4 pressure ulcer, and total dependency for all activities of daily living, was found without access to a specialized call light. The resident's care plan documented the need for a call light to be within reach and specified the use of a bell for assistance, but during observation, the standard call light was found on the floor and out of reach. The resident reported being unable to use the standard call light due to paralysis and stated that he previously used an air-activated (blow) call light in another unit, but this was not provided after his recent readmission. As a result, the resident relied on yelling for staff or using a cell phone to call for help, which was not always effective, especially at night. Staff interviews confirmed that the resident should have a call light that accommodates his disability and that the current arrangement did not meet his needs. The facility's policy requires that all residents have access to a call light within easy reach and that alternative devices be provided for those unable to use standard call lights. Despite these policies and the resident's documented needs, the appropriate specialized call light was not provided, resulting in the resident lacking a reliable means to request assistance.