Failure to Ensure Accessible Call Light for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences by not ensuring the call light was within reach while the resident was in bed. During an observation, the resident was found lying in bed with the call light hanging from the privacy curtain toward the foot of the bed, approximately six feet away and not accessible to him. When asked, the resident stated he could not reach the call light and explained that if he needed help and could not reach it, he would yell until staff came to assist him. The resident was an elderly male with severe cognitive impairment, impaired communication, unsteadiness on his feet, repeated falls, dysphagia, malnutrition, orthostatic hypotension, hypertension, hyperlipidemia, metabolic encephalopathy, subclinical hypothyroidism, urinary tract infection, and benign prostatic hyperplasia. His MDS assessment showed a BIMS score of 04, indicating severe cognitive impairment, and documented that he required substantial to maximal assistance with bed mobility, transfers, toileting hygiene, dressing, and personal hygiene, and that he had impaired balance and was a high fall risk. His care plan identified multiple problem areas, including fall risk and impaired communication, and included interventions such as reminding him to use the call device and ensuring the call light was within reach. Multiple staff interviews confirmed that the call light was not within reach and that this placement was inconsistent with expectations. CNA staff, a hospitality aide, an RN, the Administrator, and the DON all stated that call lights were supposed to be within reach of residents, and several specifically noted that in this case the call light was clipped to or hanging from the privacy curtain away from the resident. The DON also stated that the resident had a prior fall and that fall precautions included placing the call light within reach, along with a low bed and fall mat. Review of the facility’s “Call System, Resident” policy did not reveal any specific language addressing the use, placement, or requirement of call lights.
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