Call Light Not Accessible to Resident with Severe Cognitive Impairment
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple complex medical conditions, including cerebrovascular accident, seizure disorder, asthma, COPD, respiratory failure, and muscle wasting, was found unable to access their call light. During an observation, the resident was lying in bed on oxygen and reported feeling unwell, but could not call for help because the call light was stored in a closed nightstand drawer. A CNA later retrieved the call light and attached it to the resident's pillowcase, admitting that she had placed it in the drawer earlier while changing bed linens and forgot to return it within the resident's reach. Interviews with facility staff, including the CNA, DON, and Administrator, confirmed that it is the facility's policy and expectation for call lights to be accessible to all residents at all times. The facility's policy also requires staff to ensure call lights are within reach during every interaction in a resident's room. The failure to ensure the call light was accessible directly contradicted the resident's care plan, which included interventions to keep the call light within reach due to the resident's fall risk and poor safety awareness.