Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including Parkinson's disease, dementia, stroke, larynx cancer, and gastrostomy, was found unable to reach their call light while lying in bed. The resident, who is on palliative care and has significant self-care deficits due to impaired vision, physical limitations, and weakness, requires assistance for toileting, transfers, and bed mobility. During the surveyor's observation, the call light was attached to the bed but positioned approximately four inches from the resident's right upper arm, out of their reach. When asked, the resident attempted but was unable to locate or reach the call light. Despite the presence of staff in the room, including a CNA who checked the resident's blood pressure and an RN who administered medications and performed a tube feeding dressing change, neither ensured the call light was within the resident's reach before leaving. The issue was only addressed after the surveyor brought it to the attention of an LPN, who then repositioned the call light onto the resident's lap and adjusted the bed to a more appropriate angle for tube feeding. The deficiency was confirmed through observation and staff interviews, with acknowledgment from the DON after being informed of the findings.