Failure to Ensure Proper Use of Assistive Devices and Call Light Accessibility
Penalty
Summary
The facility failed to ensure proper use of assistive devices and communication tools for two residents, resulting in deficiencies related to accident prevention and resident safety. One resident, who had diagnoses including cognitive communication deficit, dementia, muscle weakness, and a history of falls, was observed being pushed in a wheelchair without the use of foot pedals. The resident's care plan and facility policy required the use of foot pedals to prevent feet from dragging and reduce fall risk, but staff did not follow this protocol. Staff interviews confirmed that the expectation was to use foot pedals when transporting residents in wheelchairs. Another resident, with severe cognitive impairment, Parkinson's disease, muscle weakness, and total dependence on staff for activities of daily living, was found with her call light out of reach on the floor. The care plan for this resident required that the call light be kept within reach at all times to allow communication of needs. Staff interviews and facility policy confirmed that call lights should be accessible to residents during each encounter, but this was not adhered to, leaving the resident unable to call for assistance.