Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to transfer or care for himself independently consistently had access to the call light system. The resident, who had a history of neck fracture, diabetes, glaucoma, and other medical conditions, was observed on multiple occasions without the call light cord within reach while in bed. Staff interviews revealed that certified nursing assistants (CNAs) and a licensed vocational nurse (LVN) acknowledged the importance of call light accessibility and confirmed that they had been trained to provide the call light to residents before leaving the room. However, both CNAs admitted to forgetting to place the call light within the resident's reach due to being rushed or distracted by other tasks. Observations documented the call light cord on the floor and hanging on the privacy curtain, both out of the resident's reach. The resident himself reported that he could not get out of bed or use the bathroom without assistance and that the call light cord was not always given to him. Facility leadership, including the DON and administrator, confirmed that all residents should have the call light within reach and were unaware that this was not being done for this resident. The facility's policy required that the call system be accessible to residents, but this was not consistently implemented for the resident in question.