Call Light Not Kept Within Reach for Resident with Cognitive Impairment
Penalty
Summary
A deficiency was identified when a resident's call light was not kept within reach, contrary to facility policy and the resident's care plan. The resident, who had a diagnosis of autistic disorder and severe cognitive impairment as indicated by a BIMS score of 7, was admitted with a history of falls and had interventions in place requiring the call light to be accessible. Multiple observations showed the call light wrapped around the bed enabler, out of the resident's reach, and both the resident and staff confirmed that the resident could not access the call light when needed. The resident reported that staff typically left the call light in this inaccessible position, and staff interviews confirmed this was not in accordance with expected practice. Staff, including a CNA and an LPN, acknowledged that the call light should have been within the resident's reach and that the resident was unable to reposition it independently. The DON and Executive Director both stated their expectation that call lights be accessible to residents at all times and that staff should check the call light's placement during each room entry. Despite these expectations and documented interventions, the call light was repeatedly found out of reach during the survey.