Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident's call light was within reach and accessible. The resident, who had a history of hemiplegia and hemiparesis following a stroke affecting the left side, chronic pain syndrome, depression, and anxiety disorder, required substantial assistance with activities of daily living, including transfers and mobility. During observation, the resident was found sitting in a wheelchair with the call light wrapped around the bed's grab bar on the far side of the room, making it inaccessible. The resident reported having to use a personal cell phone to contact family for help or self-propel to the nurses' station to request assistance, as he could not reach the call light due to his physical limitations. Interviews with nursing staff and the DON confirmed that staff were expected to ensure call lights were within reach for all residents, especially those dependent on staff for care. However, staff had not consistently followed this expectation, as evidenced by the call light being left out of reach. Facility policy also required that residents be provided with a means to call staff for assistance from their bed and other locations, but this was not adhered to in the resident's case.