Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A deficiency was identified when staff failed to ensure that a call light was within reach for a resident with severe cognitive impairment and significant physical limitations, including hemiplegia affecting the non-dominant left side and non-ambulatory status. The resident was dependent on staff for activities of daily living except eating and was at risk for falls, as documented in the care plan. The care plan specifically included an intervention to ensure the call light was within reach and to encourage its use for assistance. During observations and interviews, it was found that the resident's call light was repeatedly out of reach, including being on the floor behind the bed and on the floor while the resident was in bed. The resident reported not having access to the call light most times and stated he could use it if it were accessible. Certified Nursing Assistants confirmed during interviews that the call light was not within reach and acknowledged it should have been. Facility policy required staff to ensure call lights were within reach and secured as needed.