Failure to Ensure Accessible Call Light Systems for Residents
Penalty
Summary
The facility failed to ensure that the call light systems in the rooms of three residents were accessible, as required to reasonably accommodate their needs and preferences. Observations revealed that the call lights for these residents were not within their reach while they were in bed. Specifically, one resident's call light was placed on the nightstand next to the bed, another's was wrapped around the wall fixture, and a third resident's call light was found inside a nightstand drawer. These placements made it impossible for the residents to access the call lights when needed. The residents involved had significant cognitive and physical impairments. One resident had severe dementia and required substantial assistance with self-care, another had Alzheimer's disease and muscle atrophy with severely impaired cognition, and the third had a history of stroke with hemiparesis and moderately impaired cognition. Their care plans included interventions to keep call lights within reach due to their high risk for falls, impaired mobility, and communication deficits. Despite these documented needs, staff did not ensure the call lights were accessible during the surveyors' observations. Interviews with staff, including a CNA, ADON, RN, and the Administrator, confirmed that it was the facility's expectation and standard practice to keep call lights within reach of residents. Staff acknowledged that call lights were sometimes moved during care and not returned to an accessible position, and that regular rounding should include checking call light placement. The facility did not have a specific policy related to call lights.