Failure to Accommodate Resident Needs and Ensure Call Bell Accessibility
Penalty
Summary
The facility failed to reasonably accommodate the needs of Resident 4, who had dementia, major depressive disorder, and anxiety disorder. On January 21, 2025, Resident 4 activated her call light to request assistance to use the restroom. A Registered Nurse (Employee 1) entered the room to administer medication, was informed by Resident 4 of her need, and turned off the call light without ensuring the need was met. Employee 1 claimed to have notified a Nurse Aide (Employee 3) via communication devices, but Employee 3 was occupied with an emergent situation and delayed in assisting Resident 4. The Director of Nursing (DON) confirmed the delay and the inappropriate deactivation of the call light before Resident 4's needs were addressed. Additionally, the facility did not ensure call bell accessibility for Resident 87, who had macular degeneration, age-related nuclear cataract, and hypertension. During an observation, Resident 87 was found eating breakfast in bed with her call bell out of reach on a recliner. Her care plan, which included an intervention to keep frequently used items within reach due to a history of falls, was not followed. The DON acknowledged that the call bell should have been within Resident 87's reach.
Plan Of Correction
Preparation and evaluation of the enclosed plan of correction set forth in these documents does not constitute admission or agreement by the provider of the truth of the facts alleged or concluded set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provision of Federal and State law. F-0558- Reasonable Accommodations Needs/Preferences 1. Resident #4 - DON provided education that in the future, the aide should notify her team leader that she was in another emergent situation so another person could respond to the residents' needs. Resident #87 re-education given to the aide to ensure the call light was always within reach for resident. 2. All other resident rooms were checked on both units on 1/23/2024 and all call lights were within reach and no other concerns were identified with residents receiving services with reasonable accommodations of resident needs and preferences. 3. Policy for Call Lights- Answering has been reviewed and revised by the DON. Education provided via Relias computer education system to Healthcare staff on the revised policy to include not turning off the call light until the resident needs have been met, call lights should be within reach at all times and the importance of residents receiving services with reasonable accommodations of resident needs and preferences. This education will be completed by 2/21/2025. 4. Audits will be completed by the QA coordinator monitoring for residents receiving services with reasonable accommodations of resident needs and preferences/call lights within reach/call lights turned off when resident needs met. Audits will be done weekly X2 weeks, bi-weekly x2 weeks then monthly x2. Any immediate concern will be brought to DON for immediate attention and re-education. Audits will be reviewed at QA Meetings. All corrective actions will be completed by 2/25/25.