Failure to Accommodate Resident Needs for Accessibility and Bed Length
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of two residents regarding accessibility and comfort in their living environment. One resident, who was bedbound with impaired mobility on one side, was unable to access the light switch in his room due to a broken and shortened switch cord located out of reach. The resident reported that the cord had been broken since his admission and that he had to rely on staff to turn the light on and off, which he found frustrating and inconvenient. Observations confirmed the inaccessibility of the switch, and staff interviews revealed that although the issue had been reported to maintenance, no follow-up occurred, and the maintenance director was unaware of the problem due to lack of a formal work order. Another resident, with incomplete quadriplegia and a height of 75 inches, was found to have his feet extending past the edge of his bed mattress during multiple observations. The resident stated that the bed provided was not long enough to accommodate his height, resulting in discomfort. The maintenance director had removed the footboard to prevent pressure on the resident's feet but had not noticed the ongoing issue of the feet extending past the mattress. The director of nursing confirmed the resident's positioning and expressed concern about the resident's ankles resting at the edge of the mattress, noting the risk for skin breakdown. The administrator was unaware of the issue, as it had not been brought to her attention by staff. In both cases, the facility did not ensure that the residents' needs for accessibility and comfort were met, as staff failed to identify, report, or address the deficiencies in a timely manner. The lack of effective communication and follow-up among nursing, maintenance, and administrative staff contributed to the ongoing issues experienced by the residents.