Failure to Maintain Call Light Access, Clean Equipment, and Timely ADL Assistance
Penalty
Summary
The deficiency involves multiple failures to reasonably accommodate residents’ needs and preferences related to call light access, cleanliness of equipment and linens, and timely assistance with basic comfort needs. Surveyors observed that one resident’s wheelchair was notably soiled with white debris on the wheels and had severely cracked armrests with most of the vinyl missing. When questioned, the Central Supply staff member described the wheelchair as “a little old,” and the Wound Care Coordinator acknowledged that the wheels were not clean and that the vinyl or fake leather on the armrests was peeling off. Another resident’s fitted sheet was observed to be soiled with a dried spill and corn flakes, and the Maintenance staff member stated that the CNA had not yet come to change the linens and that the soiling was probably waste food. Surveyors also identified repeated failures to ensure call lights and bed linens were properly in place and within reach for residents who required assistance. One resident was found lying directly on the mattress with the fitted sheet at the foot of the bed and a modified call light dangling from a rack out of reach; the resident was unable to reach the call light when asked. An LPN stated that the resident moved a lot so the sheet did not stay on the bed and did not address the sheet or call light before leaving the room. Another cognitively intact resident, care planned to require assistance with ADLs and bed mobility, had a call light wrapped around the bedside table and not within reach; the resident reported that the nurse had moved it and they could no longer reach it. An LPN later confirmed that the call light was attached in a way that the resident could not reach it. A further resident, care planned as high risk for falls with an intervention for the call light to be within reach and used for assistance, was observed with the call light behind the bed and not within reach; a housekeeper present in the room stated they did not know why the call light was behind the bed. Additional failures to meet residents’ expressed needs and preferences were documented. One resident received two hamburgers without condiments and specifically requested ketchup and mayonnaise, but was provided only a single ketchup packet. Another resident with Alzheimer’s disease, pain in the right hip, repeated falls, and substantial ADL deficits was observed in the dining room with a right foot resting in a puddle of water on the floor. The resident stated that their feet were cold and wet, requested new socks, and reported that someone had said they would get new socks but never returned. A CNA confirmed the liquid was water, acknowledged that the resident sometimes dropped water when drinking and that there was “a lot of water,” and stated they were unsure how long the water had been there before indicating they would take the resident to change socks. Facility policies and resident rights documents reviewed by surveyors required that call lights be within reach at all times, that ADL assistance be provided to maintain maximal functioning, that the facility be safe, clean, comfortable, and homelike, and that resident equipment and linens be kept clean and changed when soiled.
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