Failure to Ensure Call Lights and Fluids Were Accessible to Residents
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of three residents by not ensuring call lights were within reach and by not providing fluids at the bedside as required. One resident with an anoxic brain injury and contractures, who was severely cognitively impaired and dependent on staff for activities of daily living, was observed with a call light out of reach and confirmed he could not use it. Another resident, who was cognitively intact but totally dependent for several activities of daily living, was observed on two occasions unable to reach her call light, which was either wedged between the enabler bar and mattress or had its cord tied and out of reach. Both instances were verified by staff, who then repositioned the call lights within reach after being notified. A third resident, diagnosed with anxiety and diabetes mellitus and prescribed a regular diet with nectar-thickened fluids, was observed multiple times without any fluids at the bedside. The resident was able to drink independently if fluids were placed in front of her. Staff interviews confirmed that while residents with thickened liquids were not allowed pitchers of water, they could have thickened fluids at the bedside. Facility policy required providing residents with a fresh supply of drinking water and adequate liquids, but this was not followed for the resident in question.