Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was placed within reach, as required by facility policy and staff expectations. Observations revealed that the resident, who had a history of traumatic brain injury and demonstrated intact cognition with a BIMS score of 13, was found in bed with the call light on the floor behind the bed. On a subsequent occasion, the resident was in a wheelchair next to the bed, and the call light was observed on the bed, out of the resident's reach. When asked, the resident indicated they could not reach the call light. Staff interviews confirmed that the call light should have been placed within the resident's reach. A CNA acknowledged placing the call light on the bed and admitted the resident would not be able to access it, subsequently moving it within reach. Both the DON and the Administrator stated their expectation that staff ensure call lights are always accessible to residents. The facility's policy on fall risk reduction also specified that call lights should be within reach.