Failure to Accommodate Resident Needs for Call Light Accessibility
Penalty
Summary
The facility failed to accommodate the needs and preferences of five residents by not ensuring timely and appropriate access to call lights and specialized call devices. In one instance, a resident with severe cognitive impairment and multiple medical conditions, including a tracheostomy and gastrostomy, had a care plan requiring the call light to be within reach. However, observations showed that the resident's call light was not answered promptly, with a delay of at least seven minutes during an episode of coughing and distress. The facility's policy required call lights to be answered within five minutes, and the DON confirmed that such a delay was unacceptable, especially in emergencies. Another resident with a contracture in the right arm and severe cognitive impairment was found with the call light placed on the contracted side, making it inaccessible. The RN confirmed that the call light should have been placed on the resident's strong side to allow activation if assistance was needed. Additional observations revealed that two other residents did not have their call lights within reach. One of these residents, who was dependent in most activities of daily living and had severe cognitive impairment, was found yelling for help because the call light was on a roommate's bed. The other resident, who required moderate assistance and was cognitively intact, was left in a wheelchair without the call light within reach and was unable to call for help. A fifth resident, who had a tracheostomy, gastrostomy, and was dependent in all activities of daily living, was observed with bilateral hand mittens to prevent removal of medical devices. Despite a care plan indicating the need for an adequate call light, the resident was provided with a push-button call light, which was not appropriate due to the mittens. The respiratory therapist and RN both confirmed that a touch pad call light was needed for this resident. Facility policies required call systems to be accessible and within reach, but these requirements were not met for the residents involved.