Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and resident rights to reasonable accommodation of needs and preferences. The resident was an adult female with multiple significant diagnoses, including muscle wasting and atrophy, bipolar disorder, depression, history of stroke with left-sided hemiplegia/hemiparesis, seizures, reduced mobility, anxiety disorder, and cognitive, speech, and language deficits. Her MDS showed serious mental illness, intact memory (BIMS 14), fluctuating inattention, disorganized thinking, altered level of consciousness, and daily behavioral symptoms that interfered with activities and social interactions. Functionally, she was dependent for mobility, transfers, toileting, and most ADLs, always incontinent, and reported almost constant pain at a level of nine out of ten. During observation and interview, the resident was found in bed with the call light and bed remote hanging off the left side of the bed, out of her reach, despite her inability to use her left side. She reported that it was hard to get staff to come, that she yelled because she needed help, and that she often could not find the call button because it always fell. When informed the call light was hanging on her right side, she attempted to reach for it but was unable to pull the cord within reach. She stated she sometimes called family members to contact the facility on her behalf and did not recall ever having a clip on the call light or using a touchpad-type call button. Staff interviews confirmed that the call light was expected to be within reach and that alternative devices or clips were available, but these measures were not consistently implemented for this resident. A medication aide stated she typically placed the call light and remote on the resident’s upper abdomen and acknowledged they could slide off due to the resident’s body not being a flat surface, agreeing another solution was needed. The ADON, DON, CNA, and Administrator all stated that call lights should be within reach and that clips or tying the call light to the bed could be used, and several indicated the resident had previously had a clip or pad-type button that was no longer in place. The Administrator also reported multiple instances of responding to the resident yelling and finding the call light on her chest, while the resident claimed she did not have one. The facility’s written policy required ensuring the call light is easily reachable by the resident, but at the time of surveyor observation, this requirement was not met for this resident.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.