Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident with significant physical limitations had their call light within reach at all times, as required by facility policy. The resident had a history of cerebral vascular accident (CVA) with hemiplegia affecting both sides, limited range of motion in all extremities, and was dependent on staff for bed mobility and transfers. The resident communicated basic needs by moving his right foot or leg, as documented in his care plan. However, the care plan and Kardex did not provide specific instructions regarding the use or placement of an adaptive call light for this resident. Observations revealed that the resident's call light was not consistently placed within his reach. On one occasion, the call light was found on the resident's lower left side, out of reach, and the resident was observed to be cold but unable to call for assistance. Staff interviews confirmed that the call light should have been positioned next to the resident's right foot, which was his method of communication. The Director of Nursing also verified that the Kardex lacked information about the call light placement, and the facility's policy required call lights to be within reach for residents who could use them.