Call Light Inaccessible for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with multiple sclerosis, muscle weakness, severe protein calorie malnutrition, hyperlipidemia, and hypertension was found to have their call light out of reach while lying in bed. The resident's care plan indicated a need for assistance with activities of daily living and positioning due to high risk for pressure ulcers, with documented stage three and stage four pressure ulcers present. Observation revealed the call light was hanging on the tube feeding pole, not accessible to the resident. During the observation, the resident was found crying and reported that no staff had entered the room throughout the night, resulting in no assistance with turning, repositioning, or toileting. The resident stated they experienced an episode of bowel incontinence and could not call for help. A CNA confirmed the call light was out of reach and that the resident was incontinent and unable to call for assistance. Facility policy required that call lights be within reach for residents in bed or confined to a chair, but this was not followed in this instance.