Failure to Ensure Call Light Accessibility and Safe Wheelchair Transport
Penalty
Summary
Staff failed to ensure that several residents had access to their call lights, leaving them unable to communicate their needs. During observations, multiple residents were found in their beds with call lights either on the floor, behind the bed, or otherwise out of reach. These residents attempted to locate their call lights but were unsuccessful. Interviews with staff confirmed that call lights are expected to be within reach of all residents at all times, but this was not consistently maintained. Additionally, staff were observed transporting residents in wheelchairs without foot pedals attached. Several residents, including those with severe cognitive impairment, were pushed in their wheelchairs while their feet dragged or slid on the ground. Staff interviews confirmed that foot pedals are required to be used during transport to prevent residents' feet from touching the ground. The facility's policy requires reasonable accommodation of residents' needs, including the use of assistive devices and ensuring safety during transport, but these practices were not followed.