Failure to Provide Accessible Call Lights for Dependent Residents
Penalty
Summary
The facility failed to ensure that two residents received reasonable accommodation for their needs and preferences regarding access to call lights. For one resident with a history of spondylolisthesis, neuromuscular dysfunction of the bladder, hemiplegia, and other conditions resulting in total dependence and limited use of fingers and arms, the call bell was repeatedly observed out of reach, placed on the bedside table away from the bed. The resident reported being unable to use the call bell unless it was placed near her fingers and stated she had to yell for help or rely on her roommate. The responsible party also confirmed that the call bell was not consistently within reach during visits. Facility staff, including the DON, confirmed through observation and interview that the resident was physically incapable of using the standard call bell. Another resident, with diagnoses including paroxysmal atrial fibrillation, respiratory failure, heart disease, malnutrition, and psychiatric disorders, was also found to have the call bell inaccessible, clipped to a light over the bed and out of reach. This resident, who required substantial assistance with activities of daily living and had moderately impaired cognition, stated he had to holler for assistance due to the call light not being accessible. Staff confirmed that the call bell was not within reach and that the resident was unable to utilize it due to physical limitations. Facility policy required that call lights be placed on the bed and within reach at all times, but this was not followed for these residents.