Inaccessible Call Bells for Two Residents
Penalty
Summary
The facility failed to ensure that call bells were accessible for two residents, leading to a deficiency in meeting the reasonable accommodation of resident needs and preferences. Resident 7, who had diagnoses including dysarthria, hemiplegia, hemiparesis, and anxiety, was dependent on staff for activities of daily living (ADLs) such as toileting, dressing, and personal hygiene. Despite a care plan intervention requiring staff to check that the call bell was within reach, observations on multiple occasions over several days revealed that Resident 7's call bell was tied to the light string of an adjacent bed, out of reach. Similarly, Resident 92, who had diagnoses including anxiety, bradycardia, and fibromyalgia, required partial to moderate assistance from staff for ADLs. The care plan for Resident 92 also included an intervention for staff to ensure the call bell was within reach and to encourage its use for assistance. However, observations showed that Resident 92's call bell was draped over a box on the wall behind the bed, out of reach, during multiple checks over several days. These observations indicate a failure to provide reasonable accommodation for the residents' needs, as outlined in their care plans.
Plan Of Correction
1. Residents 7 and 92 had their call bells placed within reach. 2. To identify other residents who have the potential to be affected, the DON/designee completed an audit of all resident rooms to ensure call bells are within reach. 3. To prevent this from reoccurring, DON/designee completed education with the nursing staff and all facility staff on ensuring call bells are within reach when exiting a resident room. Education for all staff is ongoing. 4. To monitor and maintain ongoing compliance, the DON/designee will audit call bell placement in 10 resident rooms weekly x 4, biweekly x 2, and monthly x 1. Results will be reviewed at the QAPI meeting.