Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call light systems were accessible to four residents reviewed for resident rights. For a female resident with muscle weakness, moderate cognitive impairment, and identified as a fall risk, the comprehensive care plan required that her call light be within reach. On observation, she was lying in bed with her call light found on the floor under the bed, contrary to her care plan and the facility’s call light accessibility policy. A second female resident with a history of stroke and paralysis of the left side, who had intact cognition and required assistance with self-care and mobility, had a care plan intervention to encourage use of the call light. During observation, she was in bed with her call light hanging on the lower portion of the left side rail, out of her reach, and she stated she was trying to get staff to help reposition her but did not know where her call light was. A male resident with lack of coordination, muscle weakness, unsteadiness on his feet, moderate cognitive impairment, and requiring assistance with self-care and mobility also had a care plan intervention to encourage use of the call light. He was observed in bed with his call light hanging on the lower portion of the left side rail, out of reach, and he stated he did not know where his call light was and wanted it to contact staff. Another male resident with lack of coordination, muscle weakness, moderate cognitive impairment, and a need for assistance with personal care and mobility had a care plan intervention to encourage use of the call light. He was observed lying in bed, stating he did not know where his call light was, and the call touch pad was found on the floor out of his reach. Multiple staff members, including CNAs, an LVN, the Unit Manager, the ADON, and the DON, acknowledged during interviews that call lights should be within reach of residents and that it was everyone’s responsibility to ensure this, and the facility’s written policy specified that the call system must be accessible to residents while in bed or other sleeping accommodations.
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