Failure to Ensure Call Light Accessibility for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and a history of falls had reasonable accommodation of needs, specifically regarding access to the call light system. On the date of observation, the resident was found lying in bed with the call light cord on the floor, approximately two feet away from the head of the bed, making it inaccessible. The resident, who had dementia, poor vision, and required staff assistance for self-care, was unable to use the call light and did not respond to questions about its use due to cognitive limitations. Staff interviews confirmed that the call light was supposed to be clipped near the resident's pillow and within reach, but this was not the case during the observation. Further interviews with facility staff, including a CNA, LVN, the Administrator, DON, and ADON, revealed that it was the expectation for all residents to have access to their call lights for safety and to request assistance. However, the facility did not have a specific policy regarding call light placement, and staff were expected to monitor and ensure accessibility during rounds. The lack of a policy and failure to ensure the call light was within reach for this resident constituted a deficiency in accommodating the resident's needs and preferences as outlined in the care plan.