Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and total dependence on staff for activities of daily living had their call light within reach while in bed. Observations on two separate occasions found the call light clipped to the privacy curtain, out of the resident's reach, while the resident was sleeping in bed. The resident's care plan specifically included interventions for call light placement within reach and prompt response, as well as reminders to use the call light for assistance. Interviews with staff confirmed that the call light was not accessible to the resident and that it was the responsibility of CNAs and nurses to ensure proper placement. The resident in question had multiple diagnoses, including epilepsy, essential hypertension, muscle weakness, and unspecified dementia, and was assessed as having severe cognitive impairment with total dependence for mobility and self-care. The facility's own policy required that call lights be within easy reach of residents when in bed or confined to a chair. Both the DON and the administrator acknowledged that the call light should have been accessible and that staff were responsible for ensuring this during rounds and room checks.