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 deficiency related to the reasonable accommodation of resident needs and preferences. For one resident, who had diagnoses including hypertension, congestive heart failure, Parkinson's Disease, dementia, and diabetes, the call light was found underneath the pillow at the head of the bed, out of the resident's reach. This resident was dependent on staff for most activities of daily living, including toileting and transfers, and had a history of falls. The care plan specifically directed that the call light should be kept within reach at all times. During observation, the resident was unable to locate the call light, and an LPN had to retrieve it from under the pillow, confirming it was not accessible as required. Another resident, with diagnoses of diabetes, hypertension, congestive heart failure, and chronic kidney disease, was observed asleep in bed with the call light hanging off the nightstand close to the ground, also out of reach. This resident required partial to moderate assistance with daily activities and used a wheelchair. Staff interviews, including those with the DON, NP, and Administrator, confirmed that facility policy and staff expectations required call lights to be within reach of residents at all times to ensure accessibility to staff assistance. Facility policy reviewed indicated that staff must ensure call lights are placed within the resident's reach when leaving the room. Despite this policy and staff awareness of the requirement, observations and interviews confirmed that the call lights for both residents were not accessible, constituting a failure to reasonably accommodate their needs and preferences as required.