Failure to Ensure Accessible Call Light System for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and total dependence on staff for activities of daily living had access to a working communication system. During an observation, the resident's call light cord was found entangled around the head of the bed frame, with the call button on the floor and out of the resident's reach while he was asleep in bed. The resident's care plan specifically required that the call light be within reach and that staff anticipate and meet his needs due to his high risk for falls and inability to communicate effectively. Interviews with facility staff, including a CNA, the DON, and the Administrator, confirmed that the call light should always be within the resident's reach and that it is the responsibility of all staff to ensure this before leaving the room. The facility's policy also required call cords to be placed within reach in resident rooms. The failure to provide a readily accessible call light system for this resident constituted a deficiency in reasonably accommodating the resident's needs and preferences as required.