Failure to Provide Suitable Call Device for Dependent Resident
Penalty
Summary
A resident with a history of cervical spinal cord injury and schizophrenia, who was dependent for all activities of daily living and had upper extremity impairment, was not provided with a call device suitable for her use. Despite the call light being placed within her reach, the resident was unable to activate it due to her physical limitations, as observed on multiple occasions. Staff interviews confirmed awareness of the resident's inability to use the standard call button, and documentation revealed that the care plan did not address her inability to use the call device. The deficiency was further evidenced by the lack of an appropriate assessment upon admission to determine the resident's need for a specialized call device. Both nursing and administrative staff acknowledged that the resident required a different type of call light, but no suitable device was provided during the period reviewed. The resident had to wait for staff to check on her for assistance, as she could not independently call for help.