Failure to Ensure Call Lights and Pad Sensors Were Accessible to Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights and pad sensors were within reach for two residents with significant physical and cognitive impairments. For one resident with quadriplegia, contractures, and severely impaired cognition, the pad sensor call light was observed placed above and on the right upper part of the bed, next to the resident's pillow, despite the resident only being able to move her left arm and hand. The Infection Prevention Nurse confirmed that the resident could not move her right arm and hand and could not reach the pad sensor call light, which should have been placed near her left arm and hand as per her care plan. The care plan specifically required the call light to be within easy reach due to the resident's high risk for falls and dependency on staff for all activities of daily living. For another resident with respiratory failure, GERD, dysphagia, and dependency on staff for personal hygiene and dressing, the call light was found inside the bedside table drawer and not within reach during two separate observations. Both a CNA and an LVN confirmed that the call light should have been accessible to the resident, and its placement in the drawer meant the resident could not call for help if needed. Facility policies reviewed indicated that call lights must be accessible to residents when in bed or in a wheelchair, and alternative communication methods should be provided and documented for residents unable to use standard call systems.