Failure to Ensure Call Light Accessibility and Accommodate Shower Preferences
Penalty
Summary
Surveyors identified that the facility failed to ensure call lights were within reach for several residents and did not accommodate a resident's shower preference. Observations revealed that one resident's call light was draped over a light fixture and later found on the floor, both times out of reach. Another resident's call light was pinned to a privacy curtain, also not within reach. Staff present during these observations confirmed that call lights should always be accessible to residents. Resident council minutes from a previous month also documented concerns about call lights being left in inappropriate locations. A third resident, who was moderately cognitively impaired and required supervision for mobility, was observed lying in bed without a call light within reach. The call cord in this case was only about two feet long and could not be reached from the bed. Interviews with staff and the Ombudsman confirmed ongoing concerns about short emergency call cords in the secure unit, with some rooms having long cords and others short, without clear policy guidance on their use. Additionally, a resident with morbid obesity, who was dependent on staff for bathing, was not provided showers due to the facility's bariatric shower chair having a weight limit below the resident's current weight. The resident expressed a desire for showers, but staff indicated there was no safe way to provide one given the equipment limitations. The facility's policy stated that resident-centered care should meet physical needs, but there was no documentation in the care plan indicating the resident preferred only bed baths, nor was there evidence that the facility sought alternative solutions to accommodate the resident's shower preference.