Failure to Ensure Call Light Accessibility and Timely Response
Penalty
Summary
The facility failed to provide reasonable accommodations to meet the care needs of three residents regarding call light accessibility and timely response. One resident, who had a history of stroke and Parkinson's disease and was at risk for incontinence, activated his call light to request a urinal but did not receive assistance for over 25 minutes, resulting in soiling his pull-ups. Documentation showed that the assigned CNA was on a scheduled lunch break, and the covering CNA went to lunch late without notifying other staff, leaving the resident's needs unmet. The resident's care plan required regular checks and toileting assistance, but these interventions were not followed during the incident. Additionally, two other residents were observed with their call lights out of reach. One resident, who had an upper extremity impairment and required substantial assistance with ADLs, was unable to access her call light, and the assigned CNA confirmed it was not within reach. Another resident, with diagnoses including schizoaffective disorder and anxiety, also had her call light on the floor and out of reach. In both cases, staff verified the call lights were not accessible to the residents, preventing them from requesting assistance when needed.