Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with a history of stroke and aphasia, who was severely cognitively impaired and dependent on staff for all activities of daily living, did not have their call light device within reach. During an observation, the call light string was found placed on top of a light fixture above the resident's head, making it inaccessible. The resident was observed attempting to communicate discomfort and was visibly tearful, indicating pain. When interviewed, the resident confirmed they could use the call light if it was within reach and affirmed experiencing pain at that time. Staff interviews revealed that the nurse was unaware of why the call light string was out of reach and acknowledged the resident's need for a more accessible call light device. The interim DON confirmed that the call light was supposed to be within the resident's reach at all times. The deficiency was based on the failure to ensure the resident's call light device was accessible, thereby not reasonably accommodating the resident's needs and preferences for requesting assistance.