Failure to Ensure Call Light Accessibility for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as required by the resident's care plan and facility expectations. On two separate observations during the same day, the resident was seen sitting in a recliner with the call light on the ground approximately two feet away, making it inaccessible. The resident, who had severe cognitive impairment and was dependent on staff for several activities of daily living, was unable to be interviewed due to his condition. The care plan specifically included an intervention to keep the call light within reach and encourage its use for assistance. Interviews with staff, including a CNA, the DON, and the ADM, confirmed that it was the responsibility of all staff to ensure call lights were within reach at all times. The CNA assigned to the resident during the observed times was not present, and the replacement CNA was unaware of the call light's position. The facility did not have a policy regarding call lights. This inaction resulted in the resident not having reasonable accommodation for his needs and preferences, as he was unable to call for assistance when needed.