Failure to Ensure Call Lights Within Reach for Residents with Cognitive Impairments
Penalty
Summary
The facility failed to ensure that the call lights were within reach for three residents with significant cognitive and communication impairments. Observations revealed that one resident was in bed without her call light within reach, and she was not able to be interviewed due to her condition. Another resident, also with Alzheimer's disease and a history of falls, was observed sitting in a reclining wheelchair in her room without a call light in reach and was similarly non-interviewable. A third resident, diagnosed with unspecified dementia and a cognitive communication deficit, was found sitting in her wheelchair with her call light placed on her bed, out of reach. This resident verbally indicated a need for help and confirmed she could use the call light if it were accessible. Record reviews for all three residents showed care plans that specifically required call lights to be kept within reach as part of ensuring a safe environment and meeting their needs. Staff interviews confirmed that there was an expectation for call lights to be accessible to all residents, regardless of their location in bed or in a wheelchair. However, one CNA stated she had not received any in-service training regarding call light placement, and the facility administrator acknowledged there was no specific policy addressing call light placement. The deficiency was identified through direct observation, interviews with staff, and review of resident records and care plans. The lack of accessible call lights for these residents, all of whom had cognitive impairments and were unable to independently communicate or seek help, constituted a failure to reasonably accommodate their needs and preferences as outlined in their care plans.