Failure to Ensure Resident Access to Bedside Light
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of borderline personality disorder was found to be unable to independently operate the bedside light in their room due to a short three to four inch chain. The resident reported frustration at being unable to turn the light on or off without assistance, requiring them to use the call bell for help. The resident's care plan did not indicate any need for a shortened chain on the bedside light. Staff interviews revealed inconsistent awareness of the resident's ability to use the light. One CNA believed the resident could use a reacher to operate the light, while an LPN stated the resident was not capable of doing so and frequently called for assistance. The RN Case Manager was unaware of the shortened chain, and the Environmental Services Director explained the chain had been shortened for safety reasons after the resident previously pulled on it to reposition, but was unaware the resident could no longer use the light independently. The Director of Nursing Services confirmed knowledge of the short chain but was not aware the resident required help to operate the light.