Failure to Ensure Functioning Call Light for Dependent Resident
Penalty
Summary
A dependent resident with severe cognitive impairment, who required substantial to maximal assistance for all activities of daily living except eating, was found to have a non-functioning call light. The resident was unable to call staff for assistance due to the call light being unplugged and a temperature probe inserted into the plug, preventing it from alarming. This issue was discovered by the resident's family member during a visit, who observed the unplugged call light and reported the incident to facility administration. The resident expressed feelings of helplessness due to being unable to call for assistance when needed. Staff interviews confirmed that the call light was not working when checked during morning rounds, and a nurse aide provided a replacement call light from an adjacent empty bed after noticing the issue. Multiple staff members, including nurse aides and a unit manager, acknowledged the tampering of the call light but were unable to determine when or by whom it had been done. The facility's expectation, as stated by the Director of Nursing and Administrator, was that all residents should have functioning call lights to request assistance.