Call Light Not Kept Within Reach for Resident on Bedside Commode
Penalty
Summary
The facility failed to ensure a resident’s call light was within reach as required by the resident’s care plan and facility policy. The resident had diagnoses including a fall, a healing left femur fracture, difficulty walking, and a communication deficit, with a BIMS score of 11 indicating moderate cognitive impairment. The resident’s care plan for fall risk, dated 10/18/25, specified that the call light should be within reach when the resident was in the room. During an observation in the resident’s room, the resident was seated on a bedside commode on the right side of the bed and stated a need for help, while the call light was positioned on the left side of the bed, out of the resident’s reach. In interviews, the CNA who had transferred the resident to the bedside commode acknowledged that the call light was out of reach and stated that the call light should always be within reach, and that the resident should have been able to press it after finishing on the commode. The resident stated that the call light should be within reach and that if it was not, it would take a while for someone to help. A licensed nurse confirmed that the call light should be within the resident’s reach and that otherwise the resident would wait longer. The DON stated that residents should be able to reach their call lights at all times and that without this it would be impossible for residents to ask for help. The facility’s “Answering the Call Light” policy required that the call light be accessible to residents when in bed, on the toilet, in the shower or bathing facility, and from the floor.
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