Failure to Provide Accessible Call Light Device for Resident with Contractures
Penalty
Summary
The facility failed to provide reasonable accommodations to meet the needs and preferences of a resident with severe cognitive impairment and multiple physical disabilities, including contractures of the hands and wrists. The resident required extensive assistance with all activities of daily living and had a care plan specifying that the call light should be within reach and that staff should encourage its use for assistance. Despite this, observations on multiple occasions revealed that the call light button was out of reach, either lying on the floor or clipped to the side of the bed, making it inaccessible due to the resident's contracted hands. There was no evidence of an alternative call light device, such as a call light pad button, being provided during these observations. Interviews with staff confirmed that the resident would benefit from a call light pad button device placed on the chest, as the original call light system was not feasible for the resident's physical limitations. Staff acknowledged that the resident had not previously used the original call light system and that the lack of an appropriate device could prevent the resident from requesting assistance. The responsible party also indicated that a call light pad button would be easier for the resident to use, given the contractures. Facility leadership, including the DON and Administrator, stated that staff are responsible for ensuring call light devices are within reach and appropriate for each resident's needs. They confirmed that the original call light device was not suitable for this resident and that the care plan required individualized accommodations. Facility policies reviewed also required that adaptive devices be provided and documented for residents unable to use standard call systems, but these accommodations were not in place at the time of the observations.