Failure to Ensure Call Light Accessibility for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to ensure that a resident had her call light within reach, as required by her care plan and facility policy. The resident, an elderly female with severe cognitive impairment (BIMS score of 7), unspecified dementia, macular degeneration, weakness, and generalized anxiety disorder, was observed multiple times throughout the day with her call light on the floor between the wall and the head of her bed, out of her reach while she was in bed. The resident stated she could not reach her call light and often forgot to use it, despite being instructed by staff to ask for help. Staff interviews confirmed that fall prevention interventions for this resident included ensuring the call light was within reach and encouraging its use for assistance. Multiple staff members, including CNAs and LVNs, acknowledged the importance of keeping the call light accessible, especially for residents at high risk for falls. Despite these interventions and staff awareness, the call light was repeatedly found out of reach during several observations on the same day, and staff admitted to having just been in the room without ensuring the call light was accessible. Facility policies and recent in-service trainings emphasized the requirement for call lights to be within reach and for staff to check on residents at least every two hours. Both the DON and the administrator stated that staff were expected to ensure call lights were accessible during rounds and whenever entering a resident's room. However, these expectations were not met, resulting in the resident being left without the ability to call for assistance as needed.