Failure to Ensure Call Light Accessibility for Dependent Residents
Penalty
Summary
The facility failed to ensure that the call light systems in the rooms of three residents were accessible, as required by their care plans and facility policy. Observations on the specified date revealed that one resident's call light was hanging on the bed railing and not within reach, another resident's call light was found on the floor and out of reach, and a third resident's call light was also on the floor behind a side table. All three residents had severe cognitive impairments and required significant assistance with daily activities, including personal hygiene, transfers, and mobility. Their care plans specifically included interventions to keep call lights within reach due to their risk for falls and dependence on staff for assistance. Interviews with staff, including a CNA, LVN, and two ADONs, confirmed that call lights should always be within reach of residents, especially those who are dependent or have limited mobility. Staff acknowledged that they had not noticed the call lights were inaccessible during their rounds and recognized the importance of ensuring accessibility to address residents' needs and prevent incidents such as falls. The facility's policy also required that call lights be within easy reach of residents who are in bed or confined to a chair. Record reviews for each resident showed that their care plans included the intervention to keep call lights within reach, and there was no documentation indicating any refusal by the residents to have their call lights accessible. The deficiency was identified through direct observation, interviews, and review of care plans and facility policy, demonstrating a failure to reasonably accommodate the needs and preferences of the residents as required.