Failure to Provide Accessible and Usable Call Lights for Multiple Residents
Penalty
Summary
The facility failed to ensure reasonable accommodation of resident needs and preferences regarding the accessibility and usability of call lights for seven residents. Multiple residents were observed with call lights out of reach or unable to operate their call lights due to physical or cognitive limitations. For example, one resident with muscle weakness and impaired cognition was found lying in bed unable to reach the call light, and another resident with Parkinson's disease and severe cognitive impairment was seated in a wheelchair with the call light hanging from the wall, out of reach. In both cases, staff confirmed the call lights were not accessible as required by facility policy and the residents' care plans. Additional deficiencies were identified for two residents who had severe memory problems and were unable to use the call light system, yet their care plans did not include interventions addressing this inability. One resident was observed calling out for assistance with pain, unable to locate or use the call light, while another could not retrieve food on her tray and did not know where her call light was. Staff interviews confirmed that the lack of specific care plan interventions for these residents' inability to use the call light could result in unmet needs and neglect of care. Another resident with hands wrapped in elastic bandages due to a history of stroke was observed struggling to activate the standard call light, requiring multiple attempts and significant effort to do so. Staff acknowledged that the resident's needs were not accommodated with an appropriate call light device, despite facility policy requiring evaluation and provision of special accommodations such as touch pads or larger buttons. These failures were confirmed through observations, interviews, and record reviews, and were inconsistent with both facility policy and the individualized care plans for the affected residents.
Plan Of Correction
Plan of Correction completion date: 6.30.25 F 558 F 558