Failure to Ensure Call Light Accessibility and Safe Wheelchair Transport
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of two residents. One resident, who had diagnoses including hypertension, dementia, anxiety, major depressive disorder, and emphysema, and was assessed as having moderately impaired cognition, was found on two separate occasions with her call light clipped to the privacy curtain at the bottom of her bed, out of her reach. Her care plan specifically directed staff to ensure the call light was within her reach and to encourage her to use it for assistance. Staff interviews confirmed that call lights should always be within residents' reach and should not be clipped to the privacy curtain. Additionally, another resident was observed being pushed by staff into the dining room without foot pedals attached to her wheelchair. Staff interviews confirmed that foot pedals should be applied when pushing a resident in a wheelchair. The facility did not provide a policy regarding accommodation of needs. These actions and inactions resulted in a failure to meet the residents' needs as outlined in their care plans and facility expectations.