Call Light Not Kept Within Reach of Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a working call system was readily accessible to a resident at the bedside, as required by facility policy and the resident’s care plan. Record review showed the resident was an elderly female with non-Alzheimer’s dementia, hypertension, and anxiety, with a BIMS score of 3/15 indicating severe cognitive impairment. Her comprehensive care plan identified her as being at risk for falls related to impaired mobility and included an intervention to ensure a safe environment by keeping the call light within reach. During an observation, the resident was found sleeping in bed with the call light button on the floor to the right side of the bed, not within her reach. During an interview and observation, a CNA entered the resident’s room, located the call light cord and button on the floor, and then placed it within the resident’s reach. The CNA stated that with the call light on the floor, the resident would not be able to call for help, including if she was incontinent or having an emergency. The DON stated that the expectation was that residents should always have the call light within reach and placed on the resident’s dominant side, and that it was the responsibility of all staff members to ensure this. The Administrator similarly stated that the call light button should always be within residents’ reach, clipped to their clothes or linen where they could reach it. Review of the facility’s “Resident Call light System” policy confirmed that each resident must be provided with a means to call staff directly for assistance from the bed and toileting/bathing facilities, which was not met in this instance.
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