Failure to Ensure Call Light Accessibility for Resident with Mobility Impairments
Penalty
Summary
A deficiency was identified when a resident with dementia, hemiplegia, hemiparesis, and a history of falls was found in bed without their call light within reach. The resident, who was dependent on staff for most activities of daily living except eating and was always incontinent of bladder with an ostomy, reported that a CNA had assisted with personal care and left the call light on the unoccupied bed, making it inaccessible. The resident was unable to stand or walk independently and relied on a trapeze bar to sit up in bed. Interviews with staff confirmed that CNAs were responsible for ensuring call lights were accessible to residents before leaving the room. The facility's care plan for the resident included an intervention to ensure the call light was within reach and answered promptly, and the facility policy required all resident rooms to be equipped with a call system for staff assistance. Despite these expectations and policies, the call light was not left within reach, resulting in a failure to reasonably accommodate the resident's needs and preferences.