Failure to Ensure Functioning Call Light for Dependent Resident
Penalty
Summary
A deficiency occurred when a dependent resident with severe cognitive impairment and multiple medical conditions, including diabetes, hypertension, and dementia, was found without a functioning call light. The resident required substantial assistance with activities of daily living and was always incontinent of bowel and bladder. On the day of the incident, a family member discovered the call light unplugged, with a temperature probe cover placed in the plug to prevent it from alarming, rendering the resident unable to call for assistance. Staff interviews confirmed that the call light had been tampered with and was not operational when discovered. The nurse aide assigned to the resident noticed the call light was unplugged during morning rounds and, believing maintenance was working on it, provided a call light from an adjacent empty bed after confirming it worked. However, it was not clear how long the original call light had been nonfunctional prior to discovery. Other staff members recalled the resident was generally able to use her call light, but on this occasion, the tampering prevented its use. The issue was reported by the family member to the facility's former Administrator, who initiated a grievance. Despite efforts, the facility was unable to determine who was responsible for tampering with the call light. Interviews with staff and management confirmed the expectation that all residents should have access to functioning call lights, but this expectation was not met in this instance, resulting in the resident being unable to summon assistance as needed.