Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach while the resident was in bed. The resident had been admitted with multiple diagnoses, including metabolic encephalopathy, functional quadriplegia, type 2 diabetes, hypertension, and difficulty swallowing. The resident’s History and Physical documented that the resident did not have the capacity to understand and make decisions, and the MDS indicated severely impaired cognition. The MDS further showed the resident required supervision with eating and oral hygiene, moderate assistance with upper body dressing and personal hygiene, and maximal assistance with toileting hygiene, lower body dressing, and footwear. During an observation and interview in the resident’s room, the resident was found lying in bed, stating they required staff assistance with changing soiled briefs, and the call light was observed on the bedside table out of the resident’s reach. In a concurrent observation and interview, an LVN confirmed that the call light was out of reach and acknowledged it should be within the resident’s reach at all times. Later, a CNA reported that at the start of the shift he ensures residents’ call lights are within reach but stated he must have forgotten to check this resident’s call light position, and reiterated that all call lights should remain within residents’ reach so they can call for assistance when needed. The DON stated that call lights need to be within reach of all residents to enable them to call for assistance when needed and acknowledged that when a call light is out of reach there is a potential for delayed care, increased risk of falls, and decreased feelings of self-worth, self-esteem, and dignity. Review of the facility’s Call System policy indicated each resident is to be provided with a means to call staff directly for assistance from the bed, toileting/bathing facilities, and the floor, and the Dignity policy stated residents are to be treated with dignity and respect in a manner that promotes individuality, well-being, satisfaction with life, self-worth, and self-esteem.
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