Failure to Ensure Call Light Accessibility for Resident with Cognitive and Physical Impairments
Penalty
Summary
The facility failed to ensure that a resident's right to reasonable accommodation of needs and preferences was met, specifically regarding access to the call light. Observations revealed that the resident's call light was on the floor and not within reach, despite the care plan indicating that the call light should be kept within the resident's reach and that the resident should be reminded to use it for assistance. The resident, who had diagnoses including Alzheimer's disease, unspecified dementia, and muscular atrophy, was severely cognitively impaired, required partial to moderate assistance for mobility, and was always incontinent of bowel and bladder. The resident was able to lift her left arm and grasp a hand when prompted, but her speech was garbled, making it unclear if she could effectively use the call light without reminders. Staff interviews confirmed that the call light was not accessible to the resident and acknowledged that it should not have been on the floor. Maintenance had been working on the call light earlier, but after their departure, the call light remained out of reach. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) both recognized that the resident could use the call light with verbal reminders and that not having it within reach could prevent the resident from receiving needed assistance. Facility policy required CNAs to attend to residents' needs at all times, but this was not followed in this instance.