Failure to Ensure Call Light Accessibility and Supervision for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance devices to prevent accidents for one resident with moderately impaired cognition and multiple diagnoses, including non-Alzheimer’s dementia, depression, and cancer. The admission MDS showed a BIMS score of 12/15 and the care plan, last revised on 11/19/25, identified the resident as a moderate fall risk related to confusion, gait and balance problems, and psychoactive drug use, with an intervention initiated on 11/25/24 to ensure the call light was within reach. A Braden Scale assessment on 1/2/26 scored the resident at 16/23, indicating risk for skin breakdown. Despite these identified needs and care plan interventions, observations on 1/28/26 at 9:55 AM and 10:35 AM showed the resident seated in a recliner at the foot of the bed with the call light located at the head of the bed and not within reach, while the resident’s lower body was covered with a blanket. Further observations and interviews on 1/28/26 showed the resident did not know where the call light was and stated it “should be around here somewhere.” At 11:33 AM, the resident’s brief was confirmed to be wet, and the resident reported being unable to request assistance because the call light was not accessible. The resident’s representative also observed that the resident’s brief was wet, the resident was covered with a blanket without pants underneath, and the call light had not been within reach to request help. At 11:48 AM, the call light was activated by the resident’s guest, and at 11:53 AM a CNA answered the call light, closed the door, left the room, returned with a clean blanket, and exited at 12:04 PM with two bags of soiled linens. The DON later confirmed that staff are expected, when leaving a resident alone, to set the resident up with the call light and other needs and perform hand hygiene, and the NHA reported that the facility did not have a policy on call light use.
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