Failure to Ensure Accessible Call Light for Cognitively Impaired Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, Alzheimer's disease, dysphagia, and a lumbar fracture was found without access to a call light. During an observation, the call light cord was strung over the head of the bed and tucked between the mattress and bed frame, making it inaccessible to the resident. The resident was observed to be disheveled, unable to answer questions coherently, and unable to make eye contact. Multiple staff members, including CNAs and an LVN, confirmed during interviews that the call light was not accessible and stated that all residents, regardless of cognitive status, should have their call lights within reach. Staff acknowledged that the call light's placement could prevent the resident from calling for help in an emergency. The responsible party for the resident also stated that the call light should be within reach due to the resident's confusion and need for assistance. The Director of Nurses confirmed that the staff did not follow facility policy or in-service training regarding call light accessibility. Review of facility policy and recent in-service training minutes indicated that staff are required to ensure call lights are within reach of residents at all times. The failure to provide an accessible call light was directly observed and corroborated by staff and documentation.