Failure to Ensure Accessible Call Light for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident's right to reasonable accommodation of needs and preferences was met, specifically regarding access to the call light system. On the date of observation, the resident was found asleep in bed with the call light lying across the footboard and onto the floor, making it inaccessible. The resident did not have a roommate, and the second call light in the room was also observed on the floor. The resident was unresponsive and unable to demonstrate whether he could reach or use the call light. According to the care plan, the call light was to be kept within reach at all times due to the resident's risk for falls and impaired mobility. The resident had severe cognitive impairment, was dependent for self-care and mobility, and had a history of falls and attempts to self-transfer. Staff interviews revealed that the CNA was aware the call light was out of reach and stated that the resident often threw items, including the call light, off the bed. The CNA also indicated that the resident was not impacted by the call light being out of reach because he was not capable of using or understanding it, so staff were expected to monitor him. Facility leadership confirmed that if the care plan required the call light to be within reach, it should have been so, regardless of the resident's cognitive status. Facility policy required that each resident be provided with a means to call for assistance, and if unable to use the standard system, an alternative should be documented in the care plan. No alternative means of communication was documented for this resident.