Call Light System Not Accessible to Dependent Residents
Penalty
Summary
The facility failed to ensure that the call light system was within reach for two residents who were dependent on staff for assistance with activities of daily living. For one resident with a tracheostomy, aphonia, and moderate cognitive impairment, the call pad was observed hanging by the side of the bed, out of the resident's reach while she was sleeping. Staff interviews confirmed that residents in the subacute unit, many of whom are non-verbal and require the call pad to alert staff for help, should always have the call pad within reach. Facility policy also requires that call cords be placed within the resident's reach to enable prompt communication with nursing staff. Another resident, who had severe cognitive impairment, dysphagia, dementia, and was dependent for mobility and personal care, was observed with the call light on the floor, out of reach. Staff interviews confirmed that the call light should have been clipped to the bed and accessible, as it is the resident's first line of help. The Director of Nursing and other staff acknowledged the importance of ensuring call lights are within reach, especially for residents who are nonverbal or unable to walk, to allow them to request assistance when needed.