Failure to Provide Alternative Call System for Visually and Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an alternative means of communication for a resident who could not effectively use the call light system. The resident was an older adult with severely impaired vision, a BIMS score of 6 indicating severe cognitive impairment, and incontinence of bowel and bladder, with diagnoses including hypertensive heart disease and chronic kidney disease. The resident’s care plan addressed visual impairment with interventions to evaluate functional safety and remove environmental barriers, but it did not document that the resident was known not to use the call light or identify any alternative communication method. During observation, the resident was seen standing motionless and silent in the middle of the room, later stating she needed the bathroom; a BM odor was present in the room. When asked, the resident reported she did not know what a call light was or how to use it, and the call light cord was observed wrapped up against the wall behind the privacy curtain, making it inaccessible. Staff interviews confirmed that the resident did not use the call light and that no alternative communication method had been designated or documented. An LVN stated the resident was fully blind, could not press the call light, and would not use it even if placed within reach or clipped to her shirt; instead, staff relied on the resident shouting for help and on keeping her door open so staff could see her. A CNA, who had worked at the facility for three days, knew the resident was blind and did not think she used the call light, and reported she was not aware of any alternative method to the call system, relying instead on frequent rounding. The DON acknowledged that while the resident had used the call light in the past, there were days she might not recognize it, and confirmed that no alternative communication method had been identified or documented in the care plan. This was inconsistent with the facility’s Call System, Residents Policy, which requires that if a resident has a disability preventing use of the call system, an alternative means of communication usable by the resident must be provided and documented in the care plan.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.