Failure to Ensure Call Lights Within Reach for Cognitively and Physically Impaired Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents with significant cognitive and physical impairments. One resident, admitted with dementia, COPD, and osteoarthritis, was assessed as having severely impaired cognition and was dependent on staff for all activities of daily living. Observations revealed that this resident's call light was tucked under the pillow and not accessible, and staff interviews confirmed the resident was unaware of the call light's location. The care plan for this resident specifically required the call light to be kept within easy reach due to fall risk and impaired cognition, but this intervention was not followed. Another resident, with diagnoses including muscle weakness, lack of coordination, parkinsonism, and dementia, was also found to have their call light hanging on the wall and out of reach while sitting in bed. This resident was assessed as high risk for falls and had a care plan intervention for staff to keep the call light within reach. Both staff and the DON confirmed that call lights should be accessible at all times, especially for residents at high risk for falls. The facility's policy also required call lights to be within reach, but this was not implemented for these two residents.