Failure to Ensure Call Light Accessibility for Resident with Severe Impairments
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as required by the resident's care plan and facility policy. The resident, a male with severe cognitive impairment, legal blindness, muscle weakness, and dependence on staff for multiple activities of daily living, was observed twice in his wheelchair with his call light hanging over his nightstand approximately two feet away, making it inaccessible. The resident stated he was unaware of the call light's location due to his legal blindness and reported that staff never clipped the call light to him, leaving him unable to call for assistance unless he moved himself into the hallway or waited for staff to enter his room. Interviews with CNAs, the DON, and the administrator confirmed that it was the responsibility of all staff to ensure call lights were within reach of residents at all times. Both CNAs working the hall where the resident resided were unaware that the call light was not accessible to the resident. The facility's policy required staff to secure call lights within reach and to evaluate residents for special accommodations to use the call system, but these procedures were not followed for this resident.