Failure to Ensure Adaptive Call Bell Accessibility for Legally Blind Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that a legally blind resident's adaptive flat call bell was consistently placed within reach, preventing the resident from being able to request assistance as needed. The resident, who was moderately cognitively impaired and dependent on staff for all mobility, was observed on multiple occasions unable to locate or access the adaptive call bell. On one occasion, the call bell was hanging from the back side of the mattress, out of the resident's reach, and the resident was observed searching for it without success. On another occasion, the call bell was found in a chair four feet away from the bed, again out of reach, while the resident attempted to locate it. The resident stated that staff placed the call bell wherever they wanted, and staff interviews confirmed that the call bell was not always positioned appropriately. The resident's care plan, which noted legal blindness, did not include specific interventions to ensure the call bell was kept within reach. Staff interviews revealed a lack of awareness regarding the proper placement of the adaptive call bell, and it was also noted that the resident's adaptive call bell had been mistakenly switched with a push button call bell intended for a roommate. Both nursing staff and the Director of Nursing acknowledged that the adaptive call bell should have been within the resident's reach at all times and that the use of a push button call bell was not appropriate for a blind resident.