Failure to Ensure Call Light Accessibility for Resident with Cognitive Impairment
Penalty
Summary
A deficiency was identified when a resident with major depressive disorder, dementia, and diabetes mellitus was found in bed without access to her call light, which was observed on the floor under the bed. The resident, who had severe cognitive impairment and was assessed as unsteady on her feet and requiring assistance from two staff members, stated that she had to yell for help and did not know how the call light ended up on the floor. The resident's care plan, which was revised to address her risk for falls due to muscle weakness, included an intervention to ensure the call light was within reach. Interviews with facility staff confirmed that the assigned nurse was unaware of how the call light became inaccessible but acknowledged the potential for negative outcomes if the resident could not call for assistance. The DON emphasized the importance of call light accessibility and stated that charge nurses monitor this during daily rounds. Facility policy requires that the call light be placed within the resident's reach before staff leave the room.