Failure to Ensure Call Lights Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, resulting in a lack of reasonable accommodation for their needs and preferences. For one resident with vascular dementia and severe cognitive impairment, the call light was observed to be pinned between two pillows underneath her, making it inaccessible. Her care plan specifically included an intervention to ensure the call light was available due to her risk for falls and need for extensive assistance with mobility and toileting. Another resident, diagnosed with unspecified dementia and a cognitive communication deficit, was found with his call light on the floor next to the head of the bed while he was sleeping, making it unreachable. This resident was dependent on staff for bed mobility, transfers, and toileting, and his care plan also required the call light to be within reach and for staff to encourage its use. Interviews with the DON, LVN, and CNA confirmed that all staff were responsible for ensuring call lights were accessible to residents, and that in-services on this topic had been conducted. Facility policy also required that each resident be provided with a means to call staff for assistance from their bed.