Failure to Keep Call Light Within Reach of Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow its call light policy by not ensuring a cognitively intact resident with left-sided weakness could access the call light. The resident had diagnoses including hemiplegia and hemiparesis following cerebrovascular disease affecting the left non-dominant side, major depressive disorder, and dysphagia following cerebral infarction. An MDS dated February 16, 2026 documented a BIMS score of 15/15, indicating intact cognition, and Section GG showed the resident required varying levels of assistance with eating, oral hygiene, personal hygiene, toileting, dressing, footwear, and bathing. On observation at 12:26 PM, the resident was seated in a mechanical chair on the right side of the bed, while the call light was placed on the bed out of the resident’s reach. The resident stated they could not reach the call light due to left-sided weakness from a stroke, demonstrated an inability to reach it with the left hand, and reported needing to shout for help and keeping a cell phone nearby because the call light was sometimes placed too far away. At 12:49 PM, a CNA and the surveyor again observed the call light on the bed out of the resident’s reach. The CNA confirmed the resident had left-sided weakness and could not stretch far enough to reach the call light where it was placed, and stated the call light needed to be closer so the resident could call staff when help was needed, otherwise the resident’s needs would not be met and the resident could fall or choke. At 1:00 PM, an RN stated that call lights should be within residents’ reach so they can access staff for help and that if not accessible, a resident might fall out of bed trying to get help or be in an emergency and unable to reach staff. At 3:45 PM, the DON stated call lights should be placed close enough for residents to reach to call for assistance and that if the call light is far from a resident, the resident will not be able to call for assistance. The facility’s call light policy dated June 30, 2025 documented that call lights must be placed within reach of residents who are able to use them at all times, which was not followed in this case.
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