Failure to Ensure Call Lights Within Reach for Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents who were both severely cognitively impaired, as documented in their quarterly MDS assessments. Multiple observations over several days showed that one resident was repeatedly found in bed without a call light within reach, with the device noted to be hanging on a curtain instead. Staff interviews confirmed that the expectation was for all residents to have call lights within reach, but staff admitted to forgetting to provide this for the resident. Another resident, also severely cognitively impaired, was observed in bed with the call light out of reach on multiple occasions. During these times, the resident was noted to be yelling. Staff, including the Interim Director of Nursing Services, acknowledged that all residents should have access to a call light, regardless of their ability to use it. These observations and staff statements demonstrate a failure to reasonably accommodate the needs and preferences of these residents.