Failure to Ensure Call Light Accessibility and Proper Wheelchair Sizing
Penalty
Summary
Surveyors identified that the facility failed to follow its own policies to accommodate residents' needs by not ensuring that call lights were within reach for four residents and by not providing an appropriately sized wheelchair for another resident. Multiple observations revealed that call lights were either on the floor, at the foot of the bed, or otherwise out of reach for residents who required them to request assistance. In several cases, residents were unaware of the location of their call lights, and staff confirmed that the call lights should have been accessible but were not. Additionally, one resident's room was missing a second call light, and the call light system was observed to be malfunctioning, with the indicator light flashing but no sound being emitted. The report details that staff, including CNAs and LPNs, were either unaware of the call light's location or acknowledged that the call light was not within reach, contrary to facility policy and individual care plans. The Director of Nursing confirmed that call lights are expected to be within reach and that failure to do so could prevent residents from calling for help. Care plans for the affected residents specifically required that call lights be accessible and that residents be encouraged to use them for assistance, but these interventions were not consistently implemented. In addition to the call light deficiencies, one resident reported discomfort and skin irritation due to being provided with a wheelchair that was too small, despite repeated requests for a larger one. The resident demonstrated that the wheelchair was causing pressure on the thighs, and both the DON and a nurse confirmed that the wheelchair was not properly fitted. The resident's care plan included interventions to prevent skin breakdown, but the lack of an appropriate wheelchair was not addressed.