Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure a resident's call light was within reach, preventing the resident from requesting assistance as needed. The resident, who had a history of repeated falls, type 2 diabetes mellitus, and dementia, was assessed as having severely impaired cognition and required moderate assistance for activities such as toileting, dressing, and transfers. The care plan specifically instructed staff to keep the call bell within reach and provide reminders to use it. During an observation, the resident was found without a brief, which she had removed due to discomfort, and stated she could not locate her call bell. The call bell was observed hanging off the mattress and out of reach, and the resident requested assistance from the surveyor to access it. Staff interviews revealed that the nursing assistant assigned to the resident did not check the location of the call bell before leaving the room and assumed it was within reach. Another nursing assistant and the nurse confirmed that the resident typically used the call bell to request help, but on this occasion, it was not accessible. The Director of Nursing stated that staff are expected to ensure call lights are within residents' reach before exiting rooms. The failure to place the call light within reach directly led to the resident's inability to request timely assistance.