Failure to Ensure Call Light Accessibility and Resident Education
Penalty
Summary
A deficiency occurred when a bedbound resident with blindness, muscle weakness, dysphagia, and Alzheimer's disease did not have access to a call light while in bed. During observation, the call light was not visible or within reach of the resident, and the resident stated they were unaware of what a call light was, indicating they had not been educated on its use. The call light was later found on a nightstand under a pillow, out of the resident's reach by more than an arm's length. Staff interviews confirmed that the call light should have been accessible and that education on its use is required upon admission. The CNA admitted to forgetting to check the call light's placement, and the LVN and DSD both acknowledged the importance of call light accessibility and resident education, especially for newly admitted, visually impaired, and primarily Spanish-speaking residents. Facility policy requires that residents be instructed on the use of the call system upon admission.