Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to provide reasonable accommodations for resident needs by not ensuring that the call light was within reach for two residents. For one resident with limited mobility, muscle weakness, pressure-induced deep tissue injuries, and a history of falls, multiple care plans specified that the call light should be within easy reach at all times and that the resident should be encouraged to use it for assistance. However, during an observation, the call light was found above the resident's head, resting on the mattress and facing the back wall, making it inaccessible. The resident was unable to call for assistance after an incontinent episode until staff intervened. Another resident, diagnosed with pressure ulcers and functional quadriplegia, also had care plans indicating the need for the call light to be within reach and for staff to encourage its use. During observation, the call light was clipped to the top of the mattress and left dangling off the side of the bed, again not within the resident's reach. Staff confirmed that if the call light was not accessible, the resident could not call for help. The assigned CNA was not present at the time, but other CNAs were reportedly available in the hallway. Interviews with staff, including the DON, confirmed that nursing staff are expected to ensure call lights are in place at the beginning of each shift and that call lights should always be accessible to residents. The facility's policy also requires that the call light be accessible to residents when in bed. Despite these policies and care plan interventions, the call lights were not within reach for the two residents at the time of observation.