Failure to Ensure Call Light Accessibility for Nonverbal Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with significant medical needs, including right-sided hemiplegia, aphasia, and dementia. The resident's care plan identified the need for the call light to be within reach as an intervention to reduce fall risk, but during an observation, the call light was found coiled on the floor approximately three feet from the resident's bed, out of the resident's reach. The resident, who was unable to speak and had limited ability to communicate, could only respond to questions with head movements and was unable to indicate how long the call light had been inaccessible. Interviews with staff confirmed that the call light should have been clipped to the bed within the resident's reach, and both a CNA and an LVN acknowledged the importance of call light accessibility, especially for this resident who could not verbally call for help. The Director of Nursing also stated that lack of access to the call light could result in delayed staff response to resident needs. Review of facility policy confirmed the requirement for a comprehensive care plan with measurable objectives and timeframes to meet residents' needs, which was not fully implemented in this case.