Failure to Ensure Call Light Accessibility for Resident with Contractures
Penalty
Summary
The facility failed to ensure that a resident with significant upper and lower extremity range of motion impairment and contractures had access to a call light or alert device within reach, as required by facility policy. The resident, who had diagnoses including stroke, diabetes, and heart disease, was documented as needing total care and assistance with activities of daily living and feeding, and was non-ambulatory. Despite care plan instructions to keep the call light in reach at all times, observations and interviews revealed that the resident was unable to reach the call light tube placed on their lap or a hand bell located on a table, due to their physical limitations. Review of the resident's clinical record and therapy notes indicated ongoing issues with contractures and the use of bilateral palm guards, but the care plan did not address the progression of the resident's hand contractures or decreased range of motion that affected their ability to access the call light system or other alert devices. Staff interviews and direct observation confirmed that the resident could not activate the call light or reach the hand bell, and the care plan lacked specific interventions to accommodate these needs.