Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with quadriplegia, muscle wasting and atrophy, and acute respiratory failure was found without access to their call light. The resident, who was cognitively intact and required full assistance from two staff members, had a care plan intervention to encourage use of the call bell for assistance. During an observation, the call light was discovered inside the nightstand, out of the resident's reach. The resident reported that staff frequently left the call light inaccessible, causing distress and forcing him to call the facility's phone number for help. Interviews with staff confirmed the call light was not accessible to the resident. The assigned CNA admitted to forgetting to place the call light within reach after returning the resident to bed following a shower. The LVN acknowledged that the call light was not accessible and stated this was not good nursing practice, as the resident would be unable to call for help. The DON and ADON both emphasized the importance of call light accessibility and stated that staff are trained on this procedure, but there was no formal policy addressing the issue.