Failure to Provide Accessible Call Light for Dependent Resident
Penalty
Summary
Nursing staff failed to ensure that the call light device was within reach for a resident who was functionally quadriplegic and dependent on staff for all activities of daily living. During observation, the call light was found next to the resident's lower right hip, out of reach, and the resident reported being unable to call for help, instead relying on his roommate to summon assistance. The resident's care plan specifically indicated that the call light should be kept within reach and that staff should monitor and anticipate his needs. Interviews with the resident, his roommate, a CNA, an RN, and the DON confirmed that the resident could not access the call light and that this prevented his needs from being addressed promptly. Review of the resident's medical records showed diagnoses of functional quadriplegia, hypotension, and multiple muscle contractures, with documentation that he had the capacity to understand and make decisions but was dependent on staff for all care. Facility policy required that the call alert device be placed within the resident's reach and that adaptive devices be provided for those unable to use the standard system. Despite these requirements, the resident was not provided with an accessible call light or adaptive device, resulting in a failure to reasonably accommodate his needs and preferences.