Failure to Provide Accessible Call System During Call Light Outage
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident with quadriplegia and contractures, who was dependent on staff for all activities of daily living. Following a thunderstorm that caused the facility's call light system to fail, the resident was provided with a temporary call bell that she was physically unable to use due to her contractures and limited arm mobility. The resident reported that her only option to call for help was to yell, which she stated was unreliable. Staff interviews confirmed awareness that the resident could not use the provided bell, and that she normally used a flat push pad call light when the system was operational. Despite staff increasing the frequency of checks on the resident to every 15 to 30 minutes, no alternative communication device that the resident could use was initially provided. The care plan for the resident specifically required that the call light and personal items be kept within reach, and that she be reminded to call for assistance. The facility did not have a policy addressing call lights, and staff acknowledged that the temporary solution did not meet the resident's needs until a modified device was later provided.