Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
Staff failed to ensure that a dependent resident with quadriplegia consistently had access to a call light device. The resident, who was cognitively intact but unable to use upper or lower extremities, required maximum assistance for all activities of daily living. During an observation, a nurse aide completed catheter care and began to leave the room without providing the resident with the call button. When prompted by the surveyor, the aide retrieved the call button and placed it by the resident's head, allowing him to activate it using the right side of his head. The aide admitted to forgetting to provide the call button due to being distracted by the care task. Later, the resident was heard calling for help from his room, and the call button was found hanging off the side of the bed, out of reach. Another nurse aide entered, assisted the resident, and confirmed the call button was accessible. Interviews with the resident revealed that staff often did not provide the call button, and staff interviews confirmed that the omission was due to being busy or distracted. Both the DON and the Administrator stated that staff were expected to ensure residents had access to call bells before leaving the room.