Failure to Ensure Call Light Accessibility for Non-Communicative Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach as required by facility policy and the resident’s care plan. The resident was an adult female with acute and chronic respiratory failure with hypoxia, tracheostomy, dependence on supplemental oxygen, hemiplegia and hemiparesis following cerebral infarction, and a diagnosis of persistent vegetative state. A quarterly MDS indicated she was rarely or never understood, unable to answer cognitive questions, and required maximum assistance with all ADLs, with mobility not assessed due to her vegetative state. Her care plan identified an inability to communicate with others related to the persistent vegetative state and included an intervention for a specialized call device that was easier to operate. During observation, the resident was found in her room with no call light within reach; the call light was clipped to itself behind her on the wall. Staff interviews confirmed that the LVN and CNA who had repositioned the resident were unaware or unsure why the call light was not placed within reach, despite acknowledging that call lights were expected to be within reach of all residents, including this resident. The DON also stated that all residents, including this resident, were expected to have a call light pinned on the bed, blanket, or within reach, and referenced the resident’s potential to go into respiratory distress. Facility policy on the resident call system required that the call light be positioned within reach of the resident and accessible while in bed or other sleeping accommodations, and that if a resident could not use the call light, the nurse must determine an adequate alternative.
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