Failure to Ensure Call Bell Accessibility for Resident with Quadriplegia
Penalty
Summary
Staff failed to ensure that a resident with quadriplegia consistently had access to a call bell that could be activated independently. The resident's care plan specified the use of an easy call universal quadriplegic call bell, which could be activated by turning the head, or a soft touch call bell placed in the resident's hand while in bed. Despite this, multiple observations showed that after staff exited the resident's room, the call bell was left out of reach, either in the seat of the wheelchair or clipped to the pillowcase in a way that the resident could not activate it. The resident, who was cognitively intact, reported that staff often failed to leave the call bell within reach or accessible for activation. Interviews with staff confirmed that the expectation was for the call bell to be placed within the resident's reach and to ensure the resident could activate it. The failure to follow these procedures resulted in the resident being unable to call for assistance as needed.