Failure to Ensure Call Light Accessibility for Residents with Cognitive and Physical Impairments
Penalty
Summary
The facility failed to ensure that the call light system was accessible to two residents, both of whom had significant cognitive and physical impairments and were at risk for falls. For one resident, who had moderate cognitive impairment, lack of coordination, and a history of falls, the call light was found wedged between the mattress and bed frame, out of the resident's reach. The resident was unable to identify the location of the call light when asked. Staff interviews confirmed that call lights should be within reach and that staff are responsible for ensuring this before leaving the room. For the second resident, who had severe cognitive impairment, dementia, and a history of falls, the call light was observed on the floor by the bed while the resident was lying awake in bed. The resident did not respond verbally when asked about the call light. Staff confirmed that the call light should be within reach and that it is important for residents to have access to the call system for assistance with personal needs and emergencies. Facility policy requires that the call system be accessible to all residents, including those who are alert, confined, or confused, and specifies that the system should be accessible even to a resident lying on the floor. Despite this policy, observations and interviews revealed that staff did not consistently ensure call lights were within reach for these residents, resulting in a failure to reasonably accommodate their needs and preferences as required.