Failure to Ensure Accessible and Appropriate Call Light Systems for Residents
Penalty
Summary
The facility failed to ensure that the needs and preferences of three residents were reasonably accommodated, specifically regarding the accessibility and appropriateness of call light systems. For two residents with significant cognitive and physical impairments, the call light buttons were observed on the floor and out of reach while the residents were in bed. One resident, who had a history of spinal fracture and moderate cognitive impairment, was unable to access his call light and stated he did not know how long it had been on the floor. Another resident, with severe cognitive impairment and right-sided hemiplegia, was also unable to locate his call light, which was confirmed by staff to be on the floor. Staff interviews revealed that there should have been clips to secure the call lights within reach, and facility policy required call lights to be accessible to residents at all times. A third resident, who was bedbound with left-sided hemiplegia and aphasia following a stroke, was found to have a call light button hanging from urinary catheter tubing and resting on the floor, making it inaccessible. Staff confirmed that this resident never used the standard call light button and acknowledged that a different call system would have been more appropriate given the resident's limited movement and high dependency. Facility policy required that residents be evaluated for unique needs and that special accommodations, such as alternative call systems, be provided and documented in the care plan. These failures were identified through direct observation, resident and staff interviews, and record reviews. The lack of accessible and appropriate call systems for these residents had the potential to delay staff response and did not meet the residents' needs as required by facility policy and procedure.