Failure to Ensure Call Light Accessibility for Resident with Impaired Cognition
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident by not ensuring the call light was within the resident's reach, as required by the care plan and facility policy. The resident, who had diagnoses including generalized anxiety disorder, PTSD, psychosis, and severely impaired cognition, was unable to understand or make her needs known and required extensive assistance with activities of daily living. Multiple fall risk assessments identified the resident as high risk for falls, and the care plan specifically directed staff to keep the call light within easy reach and provide reminders to ask for assistance. During several observations, the call light was found hanging on the side of the bed rail, nearly touching the floor and not accessible to the resident. Interviews with CNAs and the MDS nurse revealed that staff intentionally kept the call light out of reach due to the resident's behavior of putting objects in her mouth and biting them. Despite this, the MDS nurse and DON confirmed that the call light should have been within reach, with increased monitoring to ensure safety. The facility's policy also required call lights to be accessible to residents in bed and other locations.