Failure to Provide Effective Call Light System for Residents with Severe Physical Impairments
Penalty
Summary
The facility failed to provide an effective call light system for two residents with quadriplegia and both upper and lower extremity impairments, resulting in unmet needs for timely assistance. One resident, who was totally dependent on staff for all activities of daily living (ADLs) and had intact cognition, was unable to use standard call bells, bed controls, or other devices due to his condition. Upon admission, this resident had to rely on a cell phone to call for help, but faced difficulties when the phone was not charged or within reach. After eight days, the facility provided a motion sensor doorbell system, but the resident reported that it was not reliably heard by staff, especially when they were in other rooms or away from the common area. The resident documented multiple instances where the call system was activated but not answered for extended periods, sometimes up to an hour or more. Staff interviews confirmed that the call light system was inadequate for residents with severe physical impairments. Staff reported that the motion sensor doorbell used by the resident was difficult to hear, especially when staff were behind closed doors or down another hallway. Additionally, high resident acuity and staffing shortages contributed to delays in responding to call lights, with staff acknowledging that it often took more than 30 minutes to answer calls. The maintenance director was aware of the resident's request for a breath-activated call light system and had attempted to find a compatible solution, but the resident continued to experience delays in receiving assistance. A second resident with quadriplegia, also totally dependent on staff for care, preferred to use a voice-activated cell phone to call the facility for help. However, during an interview, this resident was unable to successfully use the voice command system without assistance, as the phone required a restart before it could be used. The facility's policy required that call lights be accessible and functioning at all times, and that staff respond promptly to residents' requests, but these requirements were not met for residents with significant physical limitations who could not use standard call systems.