Failure to Ensure Call Light Accessibility for Resident with Visual and Cognitive Impairment
Penalty
Summary
The facility failed to ensure that a resident's right to reasonable accommodation of needs and preferences was met, specifically regarding the accessibility of the call light system. The resident involved was an elderly female with diagnoses including spondylosis and legal blindness, and she was severely cognitively impaired, requiring significant assistance with daily activities. Her care plan included an intervention to keep the call light within her reach and to inform her of its location due to her visual impairment. On the day of the survey, the resident was observed in bed with her call light placed on a shelf out of her reach. When asked, she was unaware of the call light's location and was unable to find it herself. Staff interviews confirmed that the call light should always be within reach, especially for residents with significant impairments. A nurse and a CNA both acknowledged that the call light was not accessible and that it was their responsibility to ensure it was placed appropriately after providing care. Further interviews with facility leadership, including the DON, Administrator, and ADON, confirmed the expectation that all staff are responsible for ensuring call lights are within reach of residents before leaving the room. The facility's policy on resident rights also states that residents have the right to reasonable accommodation of their needs and preferences, which includes access to communication devices such as call lights.