Failure to Keep Call Light Within Reach for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow its call light policy and a resident’s care plan requirement to keep the call light within reach so needs could be promptly identified and met. A female resident with severely impaired cognition, as documented on the MDS, was observed in bed with her lunch tray while her door was closed and her call light was on the floor, out of her reach. The surveyor heard the resident screaming from the hallway for a spoon to eat her lunch and, upon entering the room, the resident stated she needed a spoon and did not know where her call light was. Shortly thereafter, a CNA entered, provided a disposable spoon, retrieved the call light from the floor, and placed it within the resident’s reach, acknowledging that the call light should be accessible and expressing uncertainty about why it was not. Review of the resident’s care plan showed she was care planned for risk of falls with interventions that included ensuring the call light was within reach and encouraging its use for assistance, and the facility’s written call light policy required staff to place the call light where the resident could always reach it. These observations, interviews, and record reviews demonstrate that the resident’s call light was not maintained within reach as required by both her individualized care plan and the facility’s call light policy, resulting in the resident having to call out verbally for assistance instead of using the call light system.
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