Failure to Ensure Call Light Accessibility for Resident Requiring Maximum Assistance
Penalty
Summary
The facility failed to ensure that a resident's call light was accessible as required by the care plan and facility policy. The resident, who was cognitively intact and required maximum assistance with bed mobility, transfers, and toileting due to diagnoses including heart failure and a hip fracture, was observed sitting in a wheelchair during breakfast without access to her call light. The call light was attached to the bedside railing, out of the resident's reach, and the resident reported being unable to find it. The resident stated that staff often forgot to provide her with the call light when she was in her wheelchair, and she sometimes had to yell for help. Family members also reported multiple occasions where they had to provide the call light to the resident because staff did not do so, specifying that the call light should be placed across the resident's chest in bed and attached to the wheelchair handle when seated. Staff interviews revealed that nursing assistants were unaware they had not provided the call light to the resident during breakfast, believing they had done so after assisting her into the wheelchair. The director of nursing was also unaware that the resident had been without her call light for over an hour. Facility policy required that the call light be within easy reach of residents when in bed or confined to a chair, but this was not followed in the observed instance, resulting in the resident being unable to summon assistance as needed.