Failure to Ensure Call Lights Were Accessible to Residents
Penalty
Summary
The facility failed to ensure that two residents received services with reasonable accommodations for their needs and preferences, specifically regarding the accessibility of their call lights. For one resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, observations revealed that her call light was on the floor and out of reach. The resident confirmed she could not access the call light and would have to yell for assistance if needed. Staff interviews acknowledged awareness of the importance of call light placement and that the call light was not within reach at the time of observation. Another resident, also severely cognitively impaired and dependent on staff, was observed with her call light placed on top of an oxygen concentrator approximately 2.5 feet from her bed, making it inaccessible. The resident stated she could not reach the call light and instead called out for help due to pain. A CNA responded to her calls and confirmed the call light should have been clipped to the bed sheet. Staff interviews indicated knowledge of the expectation for call lights to be within reach, and that the resident sometimes threw the call light away due to her cognitive impairment. Record reviews for both residents showed care plans that included interventions to ensure call lights were within reach, and facility policy required call lights to be easily accessible for residents in bed or confined to a chair. Despite these documented expectations and staff training, observations and interviews confirmed that the call lights were not within reach for these two residents at the time of the survey.