Failure to Maintain Accessible Call Lights and Functional Electric Bed for Toileting Independence
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not maintaining call lights within reach for multiple residents and not ensuring a consistently functional electric bed for toileting independence. The facility’s own Call Lights policy required staff to keep call lights within easy reach when a resident is in bed or in a chair. Surveyors observed five residents in their rooms without accessible call lights: one resident in a wheelchair in a room smelling of bowel movement, who stated she was soiled and waiting for staff but had her call light coiled on the floor out of reach; another resident in a wheelchair who wanted fresh ice water but could not reach a call light hanging over a folded fall mat; a resident sitting on the side of a bed that was soiled with urine, with the call light coiled on the floor by the wall; a resident sitting on her bed asking for help who did not know where her call light was, later found on the floor under the bed; and another resident sitting on her bed, asking for help because she was cold and needed a blanket, whose call light was coiled on the floor out of reach. Care plans for these residents documented risks such as falls, dementia, weakness, deconditioning, incontinence, vision and hearing problems, hemiplegia, confusion, and the need for staff assistance with ADLs, and directed staff to keep call lights within reach and encourage their use. The deficiency also includes the facility’s failure to ensure an electric bed remained consistently functional for a resident who relied on it to maintain toileting independence. This resident, with diagnoses including paraplegia, muscle wasting and atrophy, abnormality of gait and mobility, and lack of coordination, was unable to walk and used a wheelchair. The resident reported independent use of a bedside commode for bowel and bladder toileting, facilitated by raising and lowering the electric bed with a remote to match the commode height for transfers. The resident stated the bed remote had been intermittently malfunctioning for months, causing the bed to become stuck at a higher position than the commode and making transfers back into bed difficult, with the commode sliding on the floor during attempts to transfer. The resident reported informing staff numerous times about the malfunctioning remote without timely resolution and described having to manipulate the wires to operate the bed. When the surveyor observed the resident attempting to use the remote, the buttons did not work, and the facility maintenance log documented issues with wires hanging from the remote and the remote not working on multiple prior dates. An LPN familiar with the resident reported that the resident does not make false statements about staff and nursing care.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.