Failure to Provide Effective Call Light Access for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences regarding access to and use of the call light system. The resident was an 80-year-old female with sepsis, diabetes, dementia, hypertension, cognitive deficits, bowel incontinence, and a Foley catheter. Her MDS reflected a BIMS score of 02, indicating severe cognitive impairment, and she was dependent for transfers and mobility with impaired upper and lower range of motion. She had a history of falls and a fall risk score of 11, categorized as high risk. Her care plan included interventions such as a low bed, call light in reach, clutter-free room, and monitoring for risk of falls. On the date of the incident, the resident experienced an unwitnessed fall in her room, landing on the left side of the bed near the wall and sustaining scratches to the right side of her face. The fall assessment documented that the resident was disoriented and that neurological checks were initiated. A nurse note indicated that shortly before the fall, the resident had been given a pain medication, and when the LVN returned to administer night medications, the resident was found on the floor with the bed in a low position and the call light in reach but not activated. The resident was unable to provide a clear explanation for the fall. The resident’s room was located three rooms away from the nurse station, and she spoke in a faint voice, making it difficult for staff to hear her if she called out verbally. Observations and interviews showed that the resident could not effectively use the assigned pressure bulb call light due to upper body impairment and cognitive decline. The call light was tied to the left side of her nightgown, but her arms were crossed away from it, and she stated she could not reach or push the call light. The Rehab Director reported that the resident had previously used a regular call light effectively but had declined and was switched to a pressure call light; however, the Rehab Director was not aware that the resident could not use the squeeze pad requiring palm or pressure dexterity and acknowledged that no other adaptive devices or training had been tried. During direct observation, the resident was unable to locate or trigger the call light even when it was placed in her hand. Staff interviews were inconsistent: some staff stated the resident could not push the call light, while another LVN stated the resident was able to trigger it and that no further accommodations were needed. The DON stated that depending on the day and time, the resident could or could not activate the call light and that the resident’s door should have been open unless care was being given. The facility’s fall policy required call bells to be positioned within reach and responded to timely, and the resident rights policy addressed the right to communication and access to services, but the facility had no specific policy on the call light system.
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.