Failure to Ensure Safe Positioning and Call Light Accessibility During Meals
Penalty
Summary
A deficiency was identified when a resident was observed during a meal in an unsafe and undignified position, with the call light out of reach. The resident, who had severe cognitive impairment and required partial to moderate assistance for eating, was found slid down in bed with her feet at the footboard and the head of the bed elevated at approximately forty-five degrees. The lunch tray was placed on the over-bed table, but the resident could not reach her water or tea. Staff interviews confirmed that the resident was routinely served meals in a reclined position and left alone to feed herself, despite facility policy requiring residents to be positioned upright for safety and dignity during meals. Facility policy also required that call lights be kept within residents' reach to allow them to summon assistance as needed. However, during the surveyor's observation, the call light was found hanging below the mattress, out of the resident's reach. Multiple staff members, including CNAs and an LPN, acknowledged the importance of keeping the call light accessible and confirmed that it was staff responsibility to ensure this before leaving the room. The resident's family and representative also reported concerns about the call light being left out of reach and the resident not receiving adequate assistance during meals. The resident had a history of diabetes, dementia, and chronic kidney disease, and had expressed a preference to remain in bed for meals. Despite this preference, facility policy and staff interviews indicated that residents should be positioned upright for meals and have all items within reach. The failure to follow these procedures resulted in the resident being left in an unsafe position during dining and without access to the call light, compromising both safety and dignity.