Failure to Maintain Accessible and Functional Room Lighting for a Resident
Penalty
Summary
The facility failed to maintain a safe and functional environment for a resident when the resident’s bed light was not in working condition and was not accessible. The resident had spinal stenosis, strabismus, and vascular dementia, with a Minimum Data Set showing moderate cognitive impairment and a need for partial to moderate assistance with bed mobility, transfers, and ambulation. During observation and interview, the resident reported that there was no usable pull cord on the light behind the head of the bed; the cord was observed to be approximately three inches long, and the resident stated she could not reach it. She further explained that even if she could reach the cord, the wall switch by the door had to be turned on first, and that when the switch was turned on, the light still did not function. The resident stated she had no control over turning her light on or off, consistently had to ask others to operate the light, and found this frustrating, especially when the sun set. A CNA confirmed that the resident could not reach the light switch, verified the pull cord length of about three inches, and confirmed that pulling the cord did not turn the light on. The Maintenance Director initially stated the issue had never been brought to his attention, but upon observing the light, confirmed it was only partially working and that the resident could not reach the pull cord. In contrast, the Business Office Manager stated that the Maintenance Director was aware the light required repair, that the issue had been mentioned multiple times in staff morning and stand-down meetings, and that it had been discussed for approximately four months without being fixed. The Regional Consultant also confirmed the Maintenance Director was aware the light required repair and stated that it was important for the resident to have access to her light to promote quality of life, that the issue affected the resident’s independence, and that it was a hazard for her not to be able to see. Facility policies and the Director of Environmental Services job description required providing a safe, hazard-free, home-like, and comfortable environment, which was not met in this situation.
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