Call Light Not Accessible for High-Risk Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and a high risk for falls was found to have their call light placed out of reach on multiple occasions. The resident, who had a history of Alzheimer’s disease and a low BIMS score indicating severe cognitive impairment, was observed in their room with the call light on the floor atop a fall mat, rather than within easy reach as required by their care plan. The resident expressed an inability to call for assistance without the call light. Certified Nursing Assistants (CNAs) confirmed during interviews that the call light was not accessible to the resident and noted that the clip used to attach the call light was broken. The Director of Nursing acknowledged that the expectation was for call lights to be within reach and recognized the risk if this was not maintained. Facility policy also required that call lights be accessible to residents when in bed, but this was not followed in this instance.