Failure to Provide Accessible Call Device for Resident with Impairments
Penalty
Summary
A deficiency occurred when a resident with non-traumatic brain dysfunction, non-Alzheimer's dementia, and depression was not provided with a call device that accommodated their needs. The resident, who had one-sided impairment and was dependent for eating and hygiene, was documented as being at risk for falls and having a vision deficit. The care plan required the call light to be kept within reach. However, multiple observations and interviews revealed the resident was unable to reliably activate the call light due to numbness in their hands and difficulty pressing the button. The call light did not activate consistently, and the resident could not visually confirm if it was working due to their vision deficit. Staff interviews indicated that after the installation of a new call light system, no formal assessment was conducted to ensure each resident could use the new devices. The touch pad call lights previously used were incompatible with the new system, and the facility had not completed call device assessments with the new system. The maintenance director and nursing staff confirmed the lack of compatibility and assessment, and the administrator acknowledged that he was not present during the installation to verify resident accommodation.