Call Lights Not Kept Within Reach of Cognitively Impaired Roommates
Penalty
Summary
Surveyors identified a deficiency in honoring residents’ rights to be treated with respect and dignity and to retain and use personal possessions when two cognitively impaired roommates were found without access to their nurse call lights. On 11/19/25 at 1:20 PM, both residents were observed lying in their beds with each nurse call light activation device coiled on the floor between the bed and wall behind the room divider curtain, out of reach. One resident only opened her eyes and stared when greeted and made no verbal response, while the other stated she would use the call light if she needed staff attention but did not know where it was and believed it might be across the room by the dresser. Record review showed both residents had Brief Interview for Mental Status and Narrative Summary Scores indicating they were severely cognitively impaired. A Restorative RN later stated that one resident likely had the physical ability but not the cognitive ability to use a call light, and believed the other resident would not be able to use a call light, expressing surprise when informed of the resident’s statement about using it if available.
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