Call Light Placement Out of Reach for Resident with Hemiplegia
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, right-sided flaccid hemiplegia, aphasia, and dysphagia was found in bed with the call light placed out of reach. The resident's care plan specifically indicated a risk for falls and included an intervention to keep the call bell within reach. During observation, the call light was located under the bed remote on the left side of the bed, but the resident was unable to stretch far enough to access it, despite being able to use the bed remote with her left hand. Interviews with staff revealed that the nursing assistant who last attended to the resident did not realize the call light was out of reach and acknowledged that it should have been left accessible, especially considering the resident's right-sided paralysis. The facility's policy also required that call lights be placed within easy reach of residents. The resident was left without access to the call light for approximately 10 minutes after being transferred from her wheelchair to her bed.