Failure to Ensure Call Lights Were Within Reach for Two Residents
Penalty
Summary
The facility failed to provide reasonable accommodation for mobility and accessibility by not ensuring that two residents' call lights were within reach while they were in bed. According to facility policy, call lights are to be placed within the resident's reach before staff leave the room. However, multiple observations revealed that both residents had their call lights positioned out of reach on several occasions, including being placed on the floor, clipped above the head with no slack, or left on a side table or under a pillow, making it difficult or impossible for the residents to access them when needed. One resident, who was severely cognitively impaired and required substantial to maximal assistance for most activities of daily living, reported that her call light was often too far away, requiring her to rely on her roommate for assistance. Observations confirmed that her call light was sometimes on the floor or stretched tightly above her head, and staff did not consistently reposition it within her reach after providing care. Her care plan specifically included the intervention to keep the call light within reach due to her risk for pressure ulcers and ADL deficits. The second resident, who had a history of stroke, repeated falls, and muscle wasting, also required significant assistance and reported difficulty reaching his call light. He stated that he had informed staff about the issue, and observations showed his call light was sometimes clipped above his head or under his pillow, both out of his reach. Staff interviews indicated awareness of the need to keep call lights accessible, but also revealed inconsistent practices and a lack of awareness about the specific issues with these residents' call light cord lengths.