Failure to Ensure Call Bell Accessibility for Cognitively Impaired Resident
Penalty
Summary
Facility staff failed to place a call bell within reach for one resident on multiple occasions, as observed on two consecutive days. The call bell was found clipped to the bottom sheet more than halfway down the bed, making it inaccessible to the resident while he was sitting up or lying in bed. During one observation, a registered nurse entered the room, interacted with the resident, and left without ensuring the call bell was within reach. The resident involved was assessed as being severely cognitively impaired, had range of motion impairment in both arms, and required staff assistance for bed mobility. Interviews with facility staff, including a CNA and a unit manager LPN, confirmed that call bells should always be within a resident's reach for safety. Facility policy also requires that call lights be easily accessible to residents when in bed or confined to a chair.