Failure to Accommodate Resident Needs for Bed Size and Call Light Accessibility
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of three residents regarding appropriate bed size and accessibility of call lights. One resident, who was 6 feet 9 inches tall and weighed 387.2 pounds, was observed lying in a standard-sized bed (36 inches by 80 inches) that was too small for his height and weight. The resident reported difficulty rolling side-to-side due to the bed's width and stated that his pillow frequently fell off the bed. Observations confirmed that a makeshift foam piece placed to fill the gap between the mattress and footboard did not fit properly or provide adequate support. The resident expressed ongoing requests for a larger bed, which had not been fulfilled at the time of the observations. Additionally, two other residents were observed with their call lights on the floor and out of reach while they were in their wheelchairs. One of these residents was moderately cognitively impaired and completely blind, requiring extensive assistance with activities of daily living. Staff interviews confirmed the call lights were not accessible to the residents at the time of observation. These failures were identified through observation, resident and staff interviews, medical record review, and review of facility policy.