Failure to Provide Accessible Call Systems for Residents
Penalty
Summary
The facility failed to ensure that a functioning call system was available and accessible for residents in the secured men's behavioral unit. Observations revealed that in one resident's room, the call system cord was lying on the floor and there was no call system box present on the wall, making it impossible for the cord to be plugged in. Interviews with staff confirmed the absence of a call system in this room and were unable to determine how long it had been inactive. Medical record review for this resident showed significant medical needs, including traumatic brain injury, kidney cancer, morbid obesity, and left-sided hemiplegia, with dependence on staff for all activities of daily living. Further observations across the unit found that in double occupancy rooms, only a single pull cord was available between the two beds, positioned in the middle of the wall and out of reach for residents while in bed. This arrangement did not provide each resident with individual access to the call system. The facility's policy required that call lights be plugged in at all times and within easy reach of residents, but this was not followed for 14 residents on the unit. The deficiency was confirmed by the administrator, who acknowledged the lack of individual call system access for these residents.