Failure to Ensure Call Light Accessibility for Multiple Residents
Penalty
Summary
The facility failed to ensure reasonable accommodation of resident needs and preferences regarding call light placement for three residents. Observations revealed that these residents did not have access to their call lights while in bed, despite care plans specifying that call lights should be within reach and secured to their blanket or pillow. In each case, the call light cords were found hanging out of reach, either in the middle of the wall or behind furniture, preventing the residents from calling for assistance when needed. One resident, a male with moderate cognitive impairment and multiple diagnoses including dementia, chronic hepatitis C, and Wernicke's encephalopathy, was observed lying in bed with his call light cord approximately six feet away. He reported being unable to get out of bed or use the bathroom without help and stated that the call light had been out of reach for at least two days. He relied on calling out to staff as they passed by his room. Another resident, a female with diabetes, heart failure, and a large diabetic ulcer, was also found with her call light cord out of reach behind her nightstand. She reported not being able to get out of bed due to pain and stated that staff did not secure the call light within her reach during rounds. A third resident, a female with dementia, bacterial infections, and mobility issues, was similarly observed with her call light cord out of reach. She was unable to transfer herself or use the bathroom independently and expressed concern about wearing a brief for too long due to her medical history. Interviews with CNAs revealed inconsistent practices regarding the frequency of checking call light placement, with one CNA stating checks occurred every 15-30 minutes and another every two hours. Despite facility policy requiring staff to ensure call lights are within reach and secured, multiple observations confirmed ongoing failures to meet this standard for the affected residents.