Failure to Ensure Call Lights Within Reach for Dependent Residents
Penalty
Summary
The facility failed to provide reasonable accommodation of resident needs and preferences by not ensuring that the call light was within reach for two residents who were dependent on staff for all activities of daily living. For one resident with chronic respiratory failure, ventilator dependence, seizure disorder, and severely impaired cognition, the care plan specifically required the call light to be within reach at all times to prevent falls or injury. However, during an observation, the call light was found hanging on the wall at the head of the bed, out of the resident's reach, after staff had finished turning and repositioning the resident. Both a CNA and an LVN confirmed that the call light should have been placed within reach before leaving the room, and acknowledged that this was not done. A second resident, also dependent on staff for activities of daily living and with diagnoses including chronic respiratory failure, chronic encephalopathy, tracheostomy, cerebral palsy, and seizure disorder, was observed lying in bed with the call light behind the head of the bed and out of reach. The care plan for this resident also required the call light to be kept within reach at all times. A CNA confirmed during the observation that the call light was not accessible and should have been placed next to the resident. Interviews with nursing staff further confirmed that facility policy and procedure required call lights to be placed within reach of residents at all times, and that failure to do so could result in a delay in care. Review of the facility's policy reiterated the requirement to always place call cords within the resident's reach, which was not followed in these instances.