Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident's call light system was accessible, as required by the resident's care plan and facility policy. The resident in question was an elderly male with a history of atherosclerotic heart disease, diabetes mellitus, severely impaired cognition, and was dependent on staff for self-care and mobility. The resident's care plan specifically included an intervention to keep the call light within reach at all times due to his immobility, chronic pain, incontinence, and decreased cognition. On the date of observation, the resident was found lying in bed asleep with the call light hanging behind the nightstand, out of his reach. Staff interviews confirmed that the call light should have been accessible to the resident at all times, and that it was important for resident safety and communication. The facility's policy also required that each resident be provided with a means to call staff directly for assistance from their bed. Multiple staff members, including the LVN, CNA, Administrator, DON, and ADON, acknowledged that the call light was not in compliance with expectations during the incident.