Failure to Ensure Accessible Call Light for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident's call light was found on the floor, out of reach, while the resident was in bed. The resident, who had significant medical conditions including cerebral infarction, epilepsy, severe cognitive impairment, dysphagia, muscle weakness, and a history of repeated falls, was dependent on staff for activities of daily living and required frequent assistance. The care plan for this resident specifically included interventions to keep the call light within reach and to anticipate and meet the resident's needs due to their high risk for falls and impaired communication. Observations and interviews revealed that staff did not consistently ensure the call light was accessible to the resident. The resident reported that staff did not round every two hours as expected and did not always ensure the call light was within reach. There were also instances where staff entered the room, turned off the call light, and left without addressing the resident's needs. The resident's roommate corroborated these statements, noting that staff did not always answer the call light and sometimes left the resident unattended for extended periods. The roommate often had to use his own call light or seek staff assistance in the hallway for the resident. Further interviews with CNAs, the DON, ADON, and the facility administrator confirmed that staff were expected to check call lights during rounds and ensure they were within reach, but these expectations were not consistently met. Staff acknowledged the importance of timely call light response and accessibility but admitted to lapses in practice. Facility policy required call lights to be placed near residents and never on the floor, but this was not followed in the case of the resident in question.