Failure to Ensure Call Light Accessibility and Bed Footboard for Two Residents
Penalty
Summary
The facility failed to ensure that two residents' needs and preferences were reasonably accommodated in accordance with facility policy. For one resident with a history of post laminectomy syndrome and mobility impairments, the call light was observed to be out of reach, lying on the floor beside the bed while the resident was sleeping. The resident's care plan specifically indicated the need to encourage use of the call light for assistance, and the facility's policy required that call lights be within reach to assure prompt assistance. Interviews with staff, including an LVN and the DON, confirmed that the call light should have been accessible to the resident at all times. For another resident with diagnoses including cerebral infarction, malnutrition, and pneumonia, the bed was found to be missing a footboard. The resident was assessed as having severely impaired cognitive skills and required substantial assistance with daily activities. Observations showed the foot of the bed was elevated to prevent the resident from sliding, but no footboard was present. A CNA confirmed the bed had been without a footboard for an extended period and had not reported it to maintenance. The DON acknowledged that the bed should have been checked and the missing footboard reported, as it was important for the resident's comfort and positioning. Facility policies reviewed indicated that maintenance services are responsible for ensuring equipment is safe and operable, and that the environment should support residents' safe functioning and well-being. The deficiencies were identified through observation, interviews, and record review, demonstrating lapses in following established procedures for resident safety and comfort.