Call Light Not Within Reach for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and bipolar disorder, was found with her call light pinned to the back upper left side of her bed, out of her reach. The resident was dependent on staff for activities of daily living, including toileting and personal hygiene, and her care plan specifically included the intervention to ensure she could use the call bell to call for assistance. At the time of observation, the resident was awake in bed but unable to communicate due to her cognitive impairment. Interviews with staff, including a CNA, the DON, and the ADM, confirmed that it is the responsibility of all staff to ensure call lights are always within reach of residents. Staff acknowledged that if a call light is not within reach, the resident would not be able to call for assistance. The ADM also confirmed that the facility did not have a written call light policy. The failure to ensure the call light was within reach constituted a lack of reasonable accommodation for the resident's needs and preferences.