Call Bell Not Accessible to Resident with Cognitive and Physical Impairments
Penalty
Summary
Facility staff failed to ensure that a resident's call bell was accessible, as observed on multiple occasions. The resident, who has diagnoses including idiopathic peripheral autonomic neuropathy, type 2 diabetes mellitus, and muscle weakness, was found with the call bell on the floor or out of reach while in bed or seated in a wheelchair. The resident's most recent assessment indicated moderate cognitive impairment. During interviews, the resident acknowledged difficulty accessing the call bell, stating they could reach it only with effort if necessary. The DON confirmed that call bells are required to be within reach of residents at all times, regardless of their location in bed or in a chair. Facility documentation, including Mosby's Textbook for Long-Term Care Assistants, also specifies that call lights must always be kept within the person's reach. Despite these requirements, repeated observations showed the call bell was not accessible to the resident, and no additional information was provided by facility leadership prior to the survey exit.