Failure to Ensure Call Light Accessibility for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that the call light was consistently within reach for a resident with severe cognitive impairment and a history of falls. The resident, diagnosed with vascular dementia, depressive disorder, and hyperlipidemia, had a BIMS score indicating severe cognitive impairment and had experienced four falls in the past five months. The care plan directed staff to remind the resident to use the call bell for assistance. However, multiple observations over several days revealed that the call light was frequently not within the resident's reach, being attached to the back of a privacy curtain or the end of the bed, making it inaccessible. On several occasions, the resident was unable to locate or reach the call light when asked, despite being instructed to use it for assistance. Staff interviews confirmed awareness of the resident's fall risk and the need to keep the call light within reach, but also noted that the resident sometimes attempted to get up without assistance and did not always use the call light. Despite these known risks and care plan interventions, the call light was not reliably placed within the resident's reach, as evidenced by repeated observations. Only on one occasion was the call light observed to be within reach and usable by the resident.