Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident with paraplegia and severe cognitive impairment had access to a call light within reach, as required by her care plan. On the date of observation, the resident was found in bed with her call light hanging on a wall-mounted lamp bracket, out of her reach. The resident was dependent on staff for personal hygiene, transfers, and bed mobility, and her care plan specifically included an intervention to keep the call light within reach to address her risk for falls and need for assistance. Multiple staff interviews confirmed that the call light was not accessible to the resident, and staff acknowledged that it should have been placed within her reach after care was provided. The facility's policy also required staff to ensure call lights were accessible to residents at all times. The deficiency was identified through observations, interviews, and record review, which demonstrated a failure to reasonably accommodate the resident's needs and preferences as required.