Failure to Ensure Call Light Accessibility for Resident with Cognitive and Physical Impairments
Penalty
Summary
A deficiency was identified when a resident with hemiplegia and hemiparesis following a stroke, who was also severely cognitively impaired and at risk for falls, was repeatedly observed without access to their call light. On two separate occasions, the resident was found either in bed or in a wheelchair with the call light cord and mechanism hanging from the wall and resting near the floor, approximately three feet away from the head of the bed and not within the resident's reach. The resident was unaware of the call light's location during both observations. Interviews with facility staff, including a scheduler and a unit manager, confirmed that the call light was supposed to be kept within reach of the resident, but noted that the resident sometimes tossed the call light away. The facility administrator stated there was no specific call light policy, but that the practice was for staff to ensure call lights were accessible to residents. Despite these expectations, the resident's call light was not made accessible, resulting in a failure to reasonably accommodate the resident's needs.