Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure a dependent resident's call light device was consistently placed within reach, as required by the resident's care plan. The resident, who had multiple sclerosis and post-polio syndrome, was dependent on staff for all activities of daily living and could only use the call bell if it was positioned directly under the side of her neck due to limited muscle control. During observations, the call bell was found clipped to the resident's upper right chest, which she stated was not accessible, and later was observed lying on the floor out of reach. The resident reported that staff often left the room without ensuring the call bell was correctly positioned, making her feel helpless. Multiple staff interviews confirmed that both nursing and therapy staff were trained to ensure call bells were within reach before leaving a resident's room, but this was not consistently practiced. On one occasion, a nurse entered the room, performed care tasks, and left without checking the call bell's placement. The assigned nursing assistant also left the resident without the call bell in reach, planning to return shortly but did not immediately do so. The speech therapist ultimately noticed the call bell was out of reach and repositioned it appropriately. Facility leadership, including the unit manager, DON, and administrator, all stated that call bells should always be within reach, regardless of the resident's ability to call out for help.