Failure to Keep Call Lights Within Reach for Multiple Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring that call lights were within reach, as required by resident rights and facility policy. For Resident #3, a male with unspecified dementia with agitation, severe cognitive impairment (BIMS score of 3), impaired range of motion in both upper and lower extremities, and extensive assistance needs for all ADLs, the care plan directed staff to keep the call light within reach and encourage its use. During observation, this resident was in bed, awake, and not interviewable, with the call light found inside a closed nightstand drawer, blocked by the bedside table and out of reach. Resident #4, a female with Alzheimer’s disease, anxiety disorder, severe cognitive impairment (BIMS score of 3), extensive assistance needs for all ADLs, limited physical mobility, and impaired visual function, also had a care plan intervention to place the call light within reach and encourage its use. Observation showed her call bell lying across the nightstand and out of her reach. Staff, including an LVN, stated that per facility policy, call bells must be within reach of each resident to enable them to call for assistance when needed and to avoid delays in providing care. Resident #1, a male with dementia, severe cognitive impairment (BIMS score of 6), bilateral lower extremity weakness, and partial to moderate assistance needs for all ADLs, had a care plan noting risk for multiple falls, impaired cognitive function, and the need for timely meeting of needs. Observation revealed his call bell lying on the nightstand on the floor, out of his reach. Multiple staff members, including CNAs, LVNs, the DON, and the Administrator, confirmed that facility policy requires call bells to be within reach of all residents at all times, and that all staff are responsible for ensuring call bells are accessible before leaving the room to prevent delays in care and emergencies. Despite this, the observed placement of call lights for these three residents did not comply with their care plans or facility policy.
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