Failure to Provide Adaptive Call Light for Resident with Quadriplegia
Penalty
Summary
A deficiency occurred when a resident with quadriplegia and chronic respiratory failure, who was dependent on staff for all activities of daily living and unable to move their arms, was not provided with an appropriate adaptive call light system. Despite the resident's cognitive abilities being intact and their ability to communicate needs, the standard call light remote was placed next to the resident's head, which the resident could not access due to paralysis. The resident reported having to make clicking sounds to call for help, which sometimes went unheard by staff, resulting in delays in receiving assistance. Interviews with facility staff revealed that an adaptive call light system, such as a tap or pad that could be activated by cheek movement, was available but had not been provided to the resident. The Director of Engineering confirmed the availability of such devices and the process for installing them upon request. The Director of Nursing acknowledged that the resident should have had an adaptive call light system based on their assessment and current condition. Facility policy required that call lights be within easy reach and that adaptive devices be provided for residents with limited mobility, but this was not followed in this case.