Failure to Ensure Call Light Accessibility and Proper DME Accommodation
Penalty
Summary
The facility failed to ensure that call lights were within reach for four residents with significant physical and cognitive impairments. Observations revealed that the call light devices for these residents were consistently placed out of sight and out of reach, such as on the floor near the foot of the bed, on a chair at the foot of the bed, or clipped to an over-bed light. Each of these residents had care plans specifying that call lights should be kept within reach to promote safety and allow them to request assistance as needed. The facility's own policy also required that call lights be accessible to residents in bed or confined to a chair, but this was not followed during multiple observations. Additionally, the facility failed to accommodate the durable medical equipment (DME) needs of a resident with complex physical disabilities, including hemiplegia, contractures, and chronic pain. Despite repeated requests and grievances from the resident, his guardian, and the Ombudsman, the facility did not ensure a proper DME assessment or timely submission of paperwork for an appropriate, comfortable, and safe wheelchair. The resident experienced ongoing discomfort and pain due to an ill-fitting wheelchair lacking necessary features such as a headrest and adequate pressure relief. Multiple communications documented the family's and Ombudsman's efforts to guide the facility through the insurance process, but the facility failed to follow through, resulting in prolonged unmet needs. Interviews with staff, including the Occupational Therapist, Social Worker, and Director of Nursing, confirmed awareness of the resident's discomfort and the family's dissatisfaction. Staff acknowledged the lack of a headrest and the resident's pain, and documentation showed that grievances were filed and marked as unresolved by the guardian. Despite these ongoing concerns, there was no evidence that the facility completed the necessary assessments or submitted required documentation to obtain a properly fitted wheelchair, nor was there documented follow-up from the Nursing Home Administrator on the grievances.