Failure to Ensure Accessible Call Light for Resident with Physical Limitations
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including multiple sclerosis, upper extremity contractures, and impaired mobility, was found unable to access their specialty call light. The call light, designed to be activated using the resident's shoulder or the back of the head due to their inability to use their hands, was observed pinned to the bed covers on the right side of the bed, out of effective reach. The resident reported attempting to get staff attention for approximately half an hour without success, resulting in unmet care needs such as oral care and assistance with getting out of bed. During the observation, the resident demonstrated that the call light could only be activated with the back of the head, and its placement did not allow for this use. Further interviews revealed that the assigned LPN was initially unaware of how the resident could use the call light and only realized after re-entering the room that it was a motion-activated device. The LPN repositioned the call light under the resident's head, confirming that the previous placement was not accessible. The resident's care plan documented extensive assistance needs and encouraged participation in ADLs, but the failure to ensure the call light was within reach directly impacted the resident's ability to request assistance. The facility's policy required call lights to be within reach of residents, but this was not followed in this instance.