Failure to Ensure Accessible and Appropriate Call Lights for Residents
Penalty
Summary
The facility failed to ensure the physical environment accommodated the needs of two residents, specifically regarding the accessibility and appropriateness of call lights. One resident with a traumatic brain injury and a voice and resonance disorder had a care plan specifying the use of a soft-touch pad call light and that the call light should be within reach. However, multiple observations showed that the resident was provided with a push-button style call light, which was sometimes not functioning and frequently placed out of reach while the resident was in a wheelchair. Another resident, who was severely cognitively impaired and had delusions, also had a care plan requiring the call light to be within reach. Observations on several occasions found this resident lying in bed with the call light on the floor and out of reach. Staff interviews confirmed that call lights should be accessible to residents at all times, but this was not consistently ensured for these residents.