Call Light Not Kept Within Reach for Resident with Cognitive and Physical Impairments
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, chronic obstructive pulmonary disease, lack of coordination, and muscle weakness was found to have their call light pad placed out of reach while lying in bed. The resident, who had moderate cognitive impairment and required varying levels of assistance with activities of daily living, stated that the CNA must have moved the call pad during care and did not return it to an accessible position. Observations confirmed that the call light remained out of reach for nearly two hours, during which time the resident was unable to call for assistance if needed. Interviews with staff, including a CNA, the ADON, and the ADM, revealed that all were aware of the policy requiring call lights to be within reach and acknowledged it was everyone's responsibility to ensure this. The facility's policy also specified that each resident must have a means to call staff for assistance from their bed, and alternative communication methods should be provided and documented if a resident is unable to use the standard system. Despite these policies and staff awareness, the call light was not returned to the resident's reach, resulting in a failure to provide reasonable accommodation for the resident's needs.