Failure to Ensure Call Light Accessibility for Resident with Cognitive Impairment
Penalty
Summary
A deficiency was identified when a resident with a history of falls, chronic heel ulcers, and moderate cognitive impairment was repeatedly observed without access to their call light. On multiple occasions, the call light was found on the floor under the bed or wrapped around the headboard hardware, out of the resident's reach. The resident was alert and able to communicate, and their care plan specifically required that the call light be kept within reach to accommodate their dependence on staff for care needs. Despite these documented needs and facility policy requiring call lights to be accessible at all times, staff failed to ensure the call light was within the resident's reach during several observations. The resident reported frequent difficulty locating the call light and confirmed that this resulted in delays in receiving care. Staff entered the room during one observation but did not reposition the call light to make it accessible. Facility policy and administrator expectations both require call lights to be within reach, but this was not consistently implemented for this resident.