Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate a resident’s needs and preferences by not ensuring the call light was within reach. Record review showed the resident was an elderly male with dementia, hypertension, COPD, coronary artery disease, chronic kidney disease, and a history of falls. His annual MDS documented a BIMS score of 0, indicating severe cognitive impairment, and that he required substantial/maximal assistance with toileting hygiene, upper and lower body dressing, and transfers. The resident’s care plan directed staff to ensure the call light was within reach and to instruct him to use it for assistance as needed. During an observation in the resident’s room, the resident was found lying in bed with the call light on the floor toward his feet, out of his reach. The resident was confused, speaking incomprehensibly, and only the word "cold" in Spanish was discernible. Multiple staff members, including CNAs and LVNs, stated in interviews that call lights were required to be within residents’ reach so they could request help, and that all direct care staff were responsible for checking this. The DON and Administrator both confirmed that call lights had to be within reach and that all nursing staff were responsible for ensuring this, and the DON further confirmed via email that the facility did not have a written policy on call lights.
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