Failure to Ensure Accessible Call Light Resulting in Incontinence Episode
Penalty
Summary
The facility failed to reasonably accommodate a resident’s needs and preferences by not ensuring the call light was accessible throughout the night. A cognitively intact resident with diagnoses including congestive heart failure and weakness was admitted on 2/27/26. A Facility Reported Incident dated 2/26/26 documented that the resident received a bed bath on the evening of 2/23/26 and the call light was not accessible until the following morning. The resident reported that no one checked on them during the night and that they needed to use the toilet. On the morning of 2/24/26 at approximately 7:40 AM, a CNA found the resident’s call light button clipped to the top corner of the mattress and untucked from under the pillow, and the resident was very upset after experiencing fecal incontinence in bed because they were unable to call for assistance. An LPN confirmed being informed that the resident was upset after the incontinence episode due to the inaccessible call light, and the Administrator acknowledged that the resident did not have access to the call light and experienced fecal incontinence. The Administrator also stated that staff were expected to check on residents at least every two hours during the shift.
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.