Failure to Keep Call Lights Accessible for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate resident needs by ensuring call lights were accessible to residents while in bed. For one resident, an older female with multiple diagnoses including cerebral infarction, type 2 diabetes, vascular dementia, Alzheimer’s disease, mood disorder, insomnia, hypertension, muscle weakness, lack of coordination, cognitive communication deficit, aphasia, and a history of adult failure to thrive, the MDS showed severe cognitive impairment and a need for assistance with activities of daily living. Her care plan identified fall risk with interventions that included keeping the call light within reach and educating her to use it for assistance, especially after an actual fall. Despite these documented needs and interventions, surveyor observation found that this resident did not have a call light within reach on her side of the room. During interview and observation, this resident stated she could not call staff when she needed assistance and that she did not have a way to call staff because she did not have a call light. She reported having asked an unidentified staff member about her call light and being told she did not have one, and that she had been without a call light for some time, though she could not specify how long. Observation revealed that her call light was not on her bed or within her side of the room but was instead intertwined with her roommate’s call light on the roommate’s bed, contrary to the care plan intervention that required a working and reachable call light. A second resident, an older female with Alzheimer’s disease, dementia, muscle weakness, osteoporosis, unsteadiness on feet, cognitive communication deficit, dysphagia, multiple contractures, normal pressure hydrocephalus, constipation, major depressive disorder, insomnia, seizures, cataract, generalized anxiety disorder, hypothyroidism, GERD, and visual hallucinations, had an MDS indicating moderate cognitive impairment and a need for assistance with ADLs. Her care plan for musculoskeletal alteration and contractures included anticipating and meeting needs and ensuring the call light was within reach. In interview, she reported having to wait a long time for staff assistance when she did use her call light and stated she was not always able to use it because it was not near her, sometimes relying on her roommate to get staff. Observation confirmed that her call light was not in her bed but was on the floor behind a mat against the wall, making it inaccessible, in violation of both her care plan and the facility’s call light policy requiring the call device to be placed within residents’ reach before staff leave the room.
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