Failure to Maintain Accessible Call Lights for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ right to reasonable accommodation of needs and preferences by not maintaining accessible call lights for four residents. For one resident with contractures, hemiplegia, hemiparesis, moderate cognitive impairment, and dependence on staff for all ADLs, the comprehensive care plan required that the call light be within reach. During observation, this resident was in bed awake with the call light lying on the floor; she stated she used the call light to call staff, did not have it, could not find it, and that this was not the first time she could not find her call light. Another resident, with epilepsy, muscle wasting, lack of coordination, unsteadiness of feet, severe cognitive impairment, and needing assistance with transfers, bed mobility, toileting, showering, dressing, and hygiene, also had a care plan intervention to keep the call light within reach and was identified as at risk for falls. During observation, this resident was in bed awake with the call light coiled on the lowest bed frame, not within reach, and did not respond when asked where the call light was. A third resident, with difficulty walking, epilepsy, repeated falls, and a fracture, had a care plan intervention to keep the call light within reach following an actual fall. This resident was observed awake in bed with the call light on the floor and stated it had been on the floor since morning and staff had not returned it to the bed. A fourth resident, with obesity, polyneuropathy, intact cognition, and needing assistance with dressing, transfers, bed mobility, hygiene, and showering, was care planned as at risk for falls with an intervention to keep the call light within reach. This resident was observed awake in bed with the call light hanging on the repositioning bar; she reported staff always hung it there and that it was difficult for her to turn to get it, expressing a desire for it to be placed where it was easier to reach. Multiple staff, including LVNs and CNAs, acknowledged during interviews that call lights are important for residents to call staff when they need something or need assistance, and that staff are responsible for ensuring call lights are within residents’ reach. The facility’s written policy on call lights required that the call system be accessible to residents while in bed or other sleeping accommodations, which was not followed in these observed instances.
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