Failure to Ensure Accessible Call Light for Dependent Resident
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident with significant physical and cognitive impairments by not providing a working communication system within easy reach. The resident, who had hemiplegia and hemiparesis following a stroke, as well as moderate cognitive impairment, was observed lying in bed unable to access the call light, which was wrapped around the right bed rail and dangling near the floor. Despite care plan interventions specifying that the call light should be within reach and on the resident's usable side, both a CNA and an RN entered and exited the room without ensuring the call light was accessible to the resident, who could only use her left side due to right-sided weakness and a sling. Interviews with staff, including the RN, CNA, DON, and ADM, confirmed the expectation that call lights should be placed within reach and on the resident's functional side. The facility's policy also required providing residents with a means of communicating with nursing staff. However, these expectations were not met, as evidenced by direct observations and staff admissions, resulting in the resident being unable to call for assistance when needed.