Failure to Maintain Safe and Accessible Equipment for Residents
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of several residents by not ensuring that essential equipment, such as wheelchairs and call lights, were in safe and functional condition. One resident, who was cognitively intact and dependent on a wheelchair for mobility, reported that both armrests of his wheelchair were worn out, wobbly, and secured with blue tape. Despite informing staff about the issue, the problem persisted, and the maintenance director acknowledged that taped or broken equipment is unsafe and should be addressed immediately. The restorative nurse and director of nursing both confirmed that wheelchairs used by residents should be in proper working order for safety. Additionally, the facility failed to ensure that call lights were within reach and in good working order for multiple residents. One resident, who had been in the facility for six months, stated he had no call light and could not call for help when needed. Observations confirmed that his call light was not visible or within reach, and staff had to retrieve it from the floor and attach it to his bed sheet. Other residents were also found without accessible call lights, with some missing the necessary string to activate the system. Staff interviews confirmed that call lights should always be within reach and attached to the bed or resident's clothing, as outlined in facility policy. The care plans for residents at risk for falls specifically included interventions to keep call lights within reach and encourage their use for assistance. However, observations revealed that call lights were often found on the floor, missing strings, or otherwise inaccessible, directly contradicting both care plans and facility policy. Staff acknowledged the importance of accessible call lights for resident safety and the need to replace missing components promptly, but these measures were not consistently implemented.