Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident who was dependent on staff for care had their call light within reach and accessible. The resident, who had diagnoses including palliative care, anxiety, depression, and chronic pain syndrome, was moderately cognitively impaired and required substantial to maximum assistance for activities such as toileting, hygiene, dressing, and bed mobility. During an observation, the resident was found lying in bed, unable to reach or locate the call light, and was heard calling for help. The call light was draped over a pillow above the resident's head, out of reach, and the resident's left hand was contracted, making it necessary for the call light to be placed on the right side. Staff present at the time acknowledged that the call light was not within reach and confirmed that it should have been accessible to the resident. Interviews with nursing assistants and an LPN confirmed that the call light was not placed appropriately and that the resident relied on it to request assistance. The nursing assistant admitted to forgetting to reposition the call light after a previous visit. The facility's policy requires that call lights be accessible to all residents, with special accommodations documented in the care plan as needed. The director of nursing stated that it is expected for all dependent residents to have their call lights within reach at all times.