Failure to Ensure Call Lights Within Reach for Residents with Cognitive and Mobility Impairments
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents who required extensive assistance and had cognitive impairments. One resident with severe cognitive impairment, dementia, and anxiety was observed on two separate occasions lying in bed with the call light on the floor, tangled and pushed against the wall, making it inaccessible. Staff interviews confirmed that the call light was not within reach and that it should have been accessible to the resident at all times, as directed by the care plan. Another resident with moderate cognitive impairment, a history of falls, and significant mobility limitations was repeatedly found without access to their call light, both in bed and in a wheelchair. Family members reported multiple instances where the call light was out of reach or under the bed, and documentation confirmed these occurrences. Staff interviews acknowledged the expectation that call lights should be within arm's reach of residents, and facility policy required call lights to be accessible to all residents.