Call Light Not Accessible to Resident with Severe Cognitive Impairment
Penalty
Summary
A deficiency occurred when staff failed to ensure that a call light was within reach for a resident with severe cognitive impairment. During an observation, the resident was found lying in bed and stated she needed help but could not get anyone. The call light devices, including a round palm pad call light, were observed wrapped around a light fixture and not accessible to the resident. Staff interviews confirmed that the resident could not have physically wrapped the call lights around the fixture herself, and that it was the responsibility of the certified nurse aide to ensure call lights were within reach during morning rounds. The licensed practical nurse and director of nursing both stated that call lights should always be accessible to residents. The resident involved had a history of cerebral infarction and was assessed as having severely impaired cognition, as indicated by a BIMS score of 00 on the most recent Minimum Data Set assessment. The facility's policy required that call lights be kept within reach of residents at all times to provide a means of communication with staff. Despite this policy, the call light was not accessible, and staff acknowledged the oversight during interviews.