Failure to Provide Accessible Call Light System for Resident with Physical Limitations
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and bilateral hand contractures had access to a call light system that accommodated her physical limitations. On observation, the resident was found lying in bed with her call light not within reach, as it was hanging on the back wall behind the bed. The resident's hands appeared contracted, and she was unable to communicate coherently. Staff interviews revealed uncertainty about whether the resident could use the standard call light button or a touch pad, and it was confirmed that no assessment had been completed upon admission to determine the resident's ability to use the call light system. The Director of Nursing (DON) and other staff acknowledged that the resident required total care and was a full code, but admitted that the admitting nurse had not assessed the resident's ability to use the call light or touch pad. The facility's policy required that residents with disabilities preventing use of the standard call system be provided with an alternative means of communication, documented in the care plan. However, this was not done for the resident in question, resulting in the resident not having a call light system accessible or suitable for her needs at the time of the survey.