Failure to Ensure Accessibility of Call Light System for Resident
Penalty
Summary
Wecare At South Hills Rehabilitation and Nursing Center was found to be non-compliant with the requirement to provide reasonable accommodations for resident needs and preferences. The facility failed to ensure that a breath-activated call light system was accessible to a resident with significant physical impairments. The resident, identified as R53, had a history of dementia, muscle weakness, rheumatoid arthritis, and was diagnosed with stiff person syndrome, which resulted in hand contractures. Despite these conditions, the facility did not have an adequate care plan in place to address the resident's specific needs for using the breath-activated call light system. Observations and interviews revealed that the call light tube was frequently turned away from the resident's face, rendering it unusable. Staff members, including a registered nurse and nurse aides, were either unaware of how the system worked or of the physician's order for 15-minute safety checks. The facility's failure to ensure the call light was within reach and to educate staff on its use led to the deficiency. The Nursing Home Administrator and Director of Nursing confirmed the oversight during the survey.
Plan Of Correction
1. R53's breath-activated call light is placed within reach and is functional. 2. All residents reviewed to ensure the call light is within reach. 3. All residents call bells will be within reach. 4. The Director of Nursing (DON)/Designee verified the placement and functionality of the call light and documented this in the resident's point of care. Kardex, and care plan were updated for this resident and any like residents. 5. The Director of Nursing/Designee will conduct training sessions for all nursing staff, focusing on the use and maintenance of specialized call lights, including breath-activated systems. Include training on the importance of following individualized care plans, physician orders, and tasks assigned in point of care. 6. The Director of Nursing/Designee will complete auditing and monitoring to 4 rooms on each unit, to be implemented by a random weekly audit for the next two weeks, then monthly for two months to ensure that all special equipment, such as breath-activated call lights, are functional, and properly placed as per the care plan, Kardex, and Point of Care tasks. 7. The facility will conduct quarterly follow-up assessments to ensure ongoing compliance and address any recurrent issues. 8. Follow-up findings will be reported to the Quality Assurance Performance Improvement committee and documented for regulatory review.