Failure to Ensure Call Light Accessibility for Dependent Residents
Penalty
Summary
The facility failed to ensure that the call light was kept within reach for two residents, both of whom had significant physical and cognitive impairments. For one resident with generalized muscle weakness, hemiplegia following a cerebral infarction, and severe cognitive impairment, observations on two separate occasions found the call light on the ground behind the head of the bed, tangled in the bed frame and not accessible to the resident. This resident was dependent on staff for dressing and required partial assistance for bed mobility. Another resident, admitted with hemiplegia, dysphagia, schizophrenia, and diabetes mellitus, was also found to have the call light on the floor behind the bed and not within reach. This resident was totally dependent on staff for activities of daily living and had a care plan indicating the call light should be within reach due to a high risk for falls and injuries. Staff interviews confirmed that call light placement is part of routine room rounds and that the call light should be within reach for resident safety and communication. Facility policy and procedure required that all residents be provided with a call system to alert nursing staff, with call cords placed within reach. Staff interviews acknowledged the importance of call light accessibility and confirmed that both licensed and unlicensed staff are responsible for ensuring call lights are within reach during rounds. The failure to keep the call lights accessible removed the residents' ability to request assistance and was identified through direct observation and staff interviews.