Failure to Ensure Call Light Accessibility for Resident with Mobility Impairment
Penalty
Summary
The facility failed to ensure that the call system was within reach for a resident who required assistance, as observed and confirmed during interviews and record review. The resident, who had a history of hypertension, weakness, and left-sided hemiplegia and hemiparesis following a stroke, reported being left wet and not changed as often as needed. During an observation, the resident was found sitting in her wheelchair, alert and able to voice her needs, but without the call light in view or within reach. The call light was later found behind the resident and out of reach by a CNA, who acknowledged that it should have been accessible. The resident's care plan indicated a communication problem and specified that the call light should be left within reach, but the care plan for bladder incontinence did not address call light accessibility. Facility policy required staff to ensure the call light was within reach and secured as needed.