Failure to Ensure Bed Remote Controls Were Accessible to Residents
Penalty
Summary
The facility failed to provide reasonable accommodations for two residents by not ensuring that their bed remote controls were within reach. During an initial tour, one resident's bed remote control was observed at the foot of the bed, out of the resident's reach, while the resident was sleeping. Medical record review indicated that this resident lacked the capacity to understand and make decisions. A certified nursing assistant (CNA) confirmed that the bed remote control should be placed within the resident's reach, as the resident was able to use it to adjust their position for comfort. A licensed vocational nurse (LVN) also acknowledged that the bed remote control should be accessible to the resident. In a separate observation, another resident's bed remote control was found hanging by the left side of the bed, not within reach. When asked, the resident expressed a preference for having the bed remote control within reach. The infection preventionist (IP) verified that the remote should have been placed within the resident's reach. Medical records showed that this resident had intact cognition and the capacity to make decisions. These observations and interviews demonstrated that the facility did not consistently ensure that bed remote controls were accessible to residents, as required.
Plan Of Correction
F 558 • How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. The bed remotes for residents 1 and 28 were placed within reach of each resident. • How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. On 6/24/25, the Director of Staff Development (DSD) conducted an audit of residents to ensure that bed remotes were accessible to all residents, unless contraindicated for safety. No additional residents were observed with bed remotes out of reach. • What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. An in-service for facility staff was initiated on 6/23/25 by the Director of Staff Development (DSD) regarding ensuring bed remotes are kept within reach of residents, unless contraindicated for safety. Inservices completed by 7/10/25. On 7/7/25, the maintenance department started installing clips on the bed remotes to ensure they are within reach of residents, unless contraindicated for safety reasons. Completion date: 7/10/25. The assistant director of nursing or designee will monitor 10 random residents (alert) from each station 3 times/week for 3 months to ensure their bed remotes are within reach. • How the facility plans to monitor its performance to make sure that solutions are sustained. The POC is integrated into the QA system. The DON/designee will provide a summary trend analysis of the findings to the facility's monthly QAPI Committee for 3 months or until such time consistent substantial compliance has been achieved as determined by the committee. Date of compliance: 7/10/25