Failure to Provide Assistance with Eating and Ensure Call Light Accessibility
Penalty
Summary
A deficiency was identified when a resident with a history of hemiparesis following a cerebrovascular accident, pulmonary edema, dementia, and other significant medical conditions did not receive appropriate assistance with eating and did not have their call light within reach. The resident was observed lying flat in bed while attempting to eat oatmeal without staff assistance, despite physician orders to keep the head of the bed elevated due to respiratory failure and pulmonary edema. The call light was found wrapped around the trapeze arm, out of the resident's reach, and no staff were present to monitor or assist during the meal. Facility records indicated that the resident required supervision and setup or cleanup assistance with eating, and was dependent on staff for all other activities of daily living. Interviews with nursing staff confirmed that call lights should always be within reach and that residents should not be laid flat while eating. The facility's policy also required staff to assist residents unable to perform activities of daily living. Despite these requirements, the resident was left unattended, in a flat position, and without access to the call light during mealtime.