Failure to Ensure Accessible Call Light for Resident with Cognitive and Physical Impairments
Penalty
Summary
The facility failed to provide a working communication system that was easily accessible for a resident with severe cognitive impairment and significant physical limitations. On the date of observation, the resident's call light was found on the floor behind the bed, out of the resident's reach, and the resident was unaware of its location. The resident required maximal or total assistance for transfers, toileting, dressing, and transferring, and had a care plan intervention specifying that the call light should be within reach and the resident encouraged to use it for assistance as needed. Interviews with staff confirmed that the call light should have been attached to the resident or within reach, and that all staff were responsible for ensuring this. Staff acknowledged that the call light not being accessible could have resulted from new equipment being brought in by hospice, and there was no policy in place regarding call lights. The lack of a working, accessible call light system directly impacted the resident's ability to call for assistance.