Failure to Ensure Call Lights and Specialty Call Lights Were Within Reach of Residents
Penalty
Summary
The facility failed to provide reasonable accommodation of resident needs and preferences by not ensuring that call lights and specialty pad call lights were within reach for several residents. In multiple instances, surveyors observed that call lights were either tied to bed rails, dangling toward the floor, or placed on the side of the resident's body that was paralyzed or immobile, making them inaccessible to the residents. Staff interviews confirmed that the call lights were not positioned according to facility policy and the residents' care plans, which required call lights to be within easy reach to allow residents to summon assistance when needed. For example, one resident with acute and chronic respiratory failure, tracheostomy, ventilator dependence, and total dependence on staff for activities of daily living was found with the call light tied to the side rail and out of reach. Another resident with hemiplegia and hemiparesis affecting the left side had the call light clipped to the left side, which was not accessible due to paralysis, despite being able to use the right arm. In both cases, staff acknowledged the error and repositioned the call lights after being prompted by surveyors. Additionally, two residents with severe contractures and total dependence on staff, who were provided with specialty pad call lights due to their limited mobility, were found with these devices placed out of reach—either hanging over the side rail or near the floor. Staff and nursing leadership confirmed that the pad call lights should have been placed on the chest or near the face to allow the residents to alert staff for assistance. Facility policies and care plans reviewed by surveyors consistently required that call lights be within reach of all residents, including those with limited mobility or cognitive impairment.