Failure to Keep Resident Call Light Within Reach at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure a working call system was available and within reach at a resident’s bedside as required by facility policy and the resident’s care plan. Record review showed the resident was an older male with unspecified dementia and Parkinson’s disease with dyskinesia, who was cognitively intact per a BIMS score of 14. His care plan identified an ADL self-care performance deficit due to muscle weakness related to Parkinson’s disease, a need for assistance by one to two staff for transfers, and a high risk for falls related to gait/balance problems and psychoactive drug use. The care plan specifically directed that his call light be kept within reach and that he receive a prompt response to all requests for assistance. During an observation and interview, the resident was found lying in bed without a call light within reach. He stated he had never had a call light in his room. The surveyor observed that the call light cord was wrapped and placed behind his roommate’s nightstand, approximately three feet from his bed, and the resident reported he did not know it was there. The roommate confirmed that the resident did not have a call light and that the roommate would press his own call light when the resident needed staff. When the roommate pressed his call light, an LVN entered the room in response, located the resident’s call light behind the nightstand, unwrapped it, and placed it within the resident’s reach, confirming it was functional and acknowledging it should have been within reach while the resident was in bed. Multiple staff interviews, including with the DOR, several LVNs, the DON, and the ADM, confirmed that the resident was capable of using his call light, even though he did not use it frequently and often sought staff by going out of his room. They each stated that the call light should always be within the resident’s reach while in his room for safety and that all staff were responsible for ensuring call lights were within reach during nursing rounds, every time staff entered a room, and as they walked down hallways. Review of the facility’s “Call System, Residents” policy stated that each resident is to be provided with a means to call staff directly for assistance from the bed, toileting/bathing facilities, and from the floor, and that the resident call system is to be routinely maintained and tested by maintenance. Despite these expectations and policies, the resident’s call light had been wrapped and stored behind the roommate’s nightstand, leaving him without an accessible means to call for assistance while in bed until it was discovered during the survey.
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