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F0919
D

Call Light Not Within Reach for Cognitively and Physically Impaired Resident

Pasadena, California Survey Completed on 04-17-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when staff failed to ensure that a call light was within reach for a resident with significant cognitive and physical impairments. The resident, who had diagnoses including rhabdomyolysis, lack of coordination, and Alzheimer's disease, was assessed as severely impaired in cognitive skills and dependent on staff for most activities of daily living. The resident's care plans specifically required that the call light be kept within reach and that staff respond promptly to requests for assistance. However, during observations, the call light was found hanging against the wall to the left side of the resident's bed and out of the resident's reach. The resident was unaware of the location of the call light, and this was confirmed by a Certified Nursing Assistant who acknowledged that the call light was not accessible to the resident. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, confirmed the importance of having the call light within reach to ensure residents can request help when needed. Review of the facility's policy also indicated that the call light should be within easy reach of residents who are in bed or confined to a chair. The failure to follow these care plan interventions and facility policy resulted in the resident being unable to access the call light to request assistance.

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