Call Light Not Kept Within Reach for Dependent Resident
Penalty
Summary
Staff failed to ensure that a resident's call light was within reach, as required by the resident's care plans and facility policy. The resident, who had diagnoses including cognitive communication deficit, generalized muscle weakness, and dementia, was assessed as having moderately impaired cognition and required moderate to total assistance with daily activities such as hygiene, toileting, and dressing. Multiple care plans for the resident specifically directed staff to keep the call light within reach to minimize fall risk, support communication, and anticipate needs. During several observations, the resident was found lying in bed with the call light either hanging behind the bed or clipped to an overhead light, both out of the resident's reach. Staff interviews confirmed that the call light was not accessible and that it had been moved during care and not returned to the resident's reach. Staff acknowledged that the resident would be unable to call for assistance in this situation. Facility policy also required staff to ensure call lights were within reach and secured as needed.