Failure to Ensure Call Lights Were Within Reach for Multiple Residents
Penalty
Summary
The facility failed to provide reasonable accommodations for three residents by not ensuring their call lights were within reach, as required by facility policy. Observations revealed that one resident, who was cognitively intact and dependent on staff for bed mobility and personal care, reported using the call light during the night due to leg pain but waited two to three hours for assistance. The resident eventually resorted to yelling for help when no one responded, and subsequent observation confirmed the call light was on the floor and not accessible. Another resident, also with decision-making capacity, was observed twice with the call light on the floor and out of reach, which was verified by a CNA who acknowledged the call light should be accessible for the resident to request help. A third resident, who had severe cognitive impairment but no physical limitations to upper or lower extremities, was observed with the call light hanging on the side of the bed and not within reach. This was confirmed by a restorative nursing assistant, who stated the resident could use the call light if it were accessible. Medical record reviews for all three residents confirmed their cognitive and physical statuses at the time of the incidents. The facility's policy requires staff to ensure call lights are within residents' reach before leaving the room, but this was not followed in these cases.