Failure to Ensure Call Light Accessibility and Communication Support
Penalty
Summary
Nursing staff failed to ensure that the call light device was within easy reach for two residents. One resident, who was blind and required substantial to maximum assistance with mobility and transfers, was observed in bed with the call light hanging on the floor, out of reach. The resident's care plan specifically included an intervention to keep the call light within reach due to a high risk for falls and visual impairment. Staff interviews confirmed the importance of keeping the call light accessible, especially for residents with visual impairments. Another resident, who had moderate cognitive impairment and required assistance with activities of daily living, was observed requesting help to retrieve the call light, which was also found hanging on the side of the bed and not within reach. The care plan for this resident indicated the need to encourage use of the call light for assistance, but this intervention was not followed at the time of observation. Staff acknowledged the importance of call light accessibility to prevent falls and ensure timely assistance. Additionally, a resident with hemiplegia, hemiparesis, and aphasia did not have a communication board available to assist with communication needs. The resident's care plan did not address aphasia, and both staff and family confirmed that a communication board had not been provided until after the issue was identified. Facility policy emphasized the use of alternative communication systems for residents with aphasia, but this was not implemented for the resident in question.