Failure to Ensure Call Light Accessibility and Timely Response to Resident Needs
Penalty
Summary
A deficiency occurred when a resident's call light was not fully connected to the wall and was not within the resident's reach, preventing the resident from requesting assistance as needed. Observations and interviews confirmed that the call light was not accessible, and staff acknowledged the issue, with one CNA stating that the call light was not working and not within reach. The resident, who was dependent on staff for toileting hygiene and had impaired mobility, was unable to alert staff and was left soiled in their briefs with urine and/or feces. The care plan for this resident specified that the call light should be placed within reach, hanging from the trapeze above the resident's head, and that staff should be educated on this preference. The care plan also required CNAs to check the resident for incontinence at least every two hours and to keep the call light accessible and answer it promptly. The resident had a history of conversion disorder, aphonia, generalized anxiety disorder, and neuropathy, and was at risk for infection and skin breakdown due to incontinence and immobility. The facility's policy required that call lights be plugged in, functioning, and accessible to residents at all times. Despite these requirements, the call light was observed to be disconnected and out of reach on multiple occasions, and maintenance had not yet completed securing the call light to the wall. The Director of Nursing confirmed that the issue with the call light's accessibility had been identified but not resolved prior to the incident.