Failure to Accommodate Resident Needs and Preferences for Call Light Access and Sleeping Arrangements
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of two residents. For one resident with acute lymphoblastic lymphoma, urine retention, and COPD, observations revealed that the call light was repeatedly found on the floor and out of the resident's reach while she was in bed. This resident was cognitively intact but required substantial to maximum assistance with bed mobility and was dependent on staff for transfers. Interviews with staff confirmed that call lights should always be within residents' reach for safety and access to assistance, and that leaving a call light on the floor was unacceptable. Another resident, admitted with a history of stroke and Alzheimer's disease and assessed as cognitively intact, reported that she was unable to sleep in her bed due to discomfort and instead slept in a recliner. She stated she had informed facility staff about the issue with her bed, but no action had been taken to address her concern. The Social Services Director acknowledged being notified about the bed issue but had not followed up, and the resident's representative confirmed that the resident had previously slept in a bed at home. Facility leadership stated that concerns about the bed should have been addressed promptly, but no resolution had occurred.