Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with quadriplegia and respiratory failure, who was cognitively intact and fully dependent on staff for care, did not have access to their call light. The resident's care plan specified that the call light should be within reach due to their risk of falls and total dependence. During multiple observations, the call light was found placed on the right side of the resident's pillow, out of their reach, and the resident confirmed they could not activate it when needed. The resident communicated that they sometimes had difficulty breathing and had to wait for staff assistance, further indicating the importance of accessible call light placement. Interviews with nursing staff and the DON confirmed that the expectation and facility policy required call lights to be within reach of all residents. Despite this, staff initially believed the resident could use the call light by nudging it with their head, but later verified that the resident was unable to do so. The facility's policy, revised in the previous year, directed staff to ensure call lights or other communication devices were accessible to each resident, which was not followed in this instance.