Call Light Not Accessible to Resident with Severe Cognitive Impairment
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and significant physical assistance needs was found lying in bed with her call light on the floor, out of her view and reach. The resident's medical history included catatonic disorder, a parathyroid gland neoplasm, and sick sinus syndrome. Her care plan specifically identified her as being at risk for falls due to impaired cognition, mobility, and lack of safety awareness, and directed that the call light be kept within reach. Observation confirmed the call light was not accessible to the resident, and staff interviews acknowledged the issue, with an LVN noting the resident was unable to call for help. The facility's policy required call lights to be positioned conveniently for residents, but this was not followed in this instance.