Failure to Ensure Accessible Call Lights for Dependent Residents
Penalty
Summary
The facility failed to ensure that the call light systems in the rooms of two residents were accessible, as required by their care plans and facility policy. Both residents had severe cognitive impairments and were dependent on staff for activities such as transfer, toileting, dressing, and personal hygiene. Observations revealed that one resident's call light was found on the floor at the foot of the bed while she was in her wheelchair, and she was unaware of its location. In the other case, the call light was observed on the floor, coiled around an IV stand, while the resident was in bed and unable to communicate its location. Interviews with staff confirmed that call lights are essential for residents to request assistance, and that staff are responsible for ensuring call lights are within reach before leaving the room. In both cases, staff acknowledged that they had not ensured the call lights were accessible after providing care or administering medication. The facility's policy requires that each resident be provided with a means to call staff for assistance from their bed and other locations, but this was not followed in these instances. The deficiency was identified through direct observation, interviews with the residents and staff, and review of medical records and care plans. The lack of accessible call lights for these residents, both of whom were at risk for falls and dependent on staff, constituted a failure to reasonably accommodate their needs and preferences as outlined in their care plans and the facility's own policies.