Call Light Not Placed Within Reach for High-Risk Resident
Penalty
Summary
The facility failed to provide reasonable accommodation of resident needs and preferences by not ensuring that the call light was within reach for a resident with significant cognitive impairment and high fall risk. The resident, who had diagnoses including sepsis, schizoaffective disorder bipolar type, dementia, and major depressive disorder, was unable to make decisions or communicate needs effectively. The resident required substantial to total assistance with activities of daily living and was assessed as high risk for falls. The care plan specifically directed staff to keep the call light within easy reach and encourage its use to minimize fall risk. During an observation, the resident was found asleep in bed with the call light on the floor at the foot of the bed, out of reach. A CNA acknowledged that after providing ADL care, she should have ensured the call light was within reach, as required by facility policy and the resident's care plan. Both the ADON and DON confirmed that staff are expected to place call lights within reach after care, and failure to do so could result in unmet needs and increased risk for the resident. The facility's policy also stated that the call system must be accessible to residents while in bed.