Non-Functional Call Light Leaves Dependent Resident Unable to Summon Assistance
Penalty
Summary
A deficiency was identified when a resident's call light was found to be non-functional, preventing the resident from being able to summon staff assistance. The issue was discovered during an observation and interview, where the resident requested help and the call light did not activate when pressed. The resident's roommate confirmed that the call light had not been working for approximately two weeks, and she had been using her own call light to request help on behalf of the affected resident. Staff members, including a CNA, verified that the call light was not working and acknowledged the risk to the resident, noting that maintenance had not been notified of the issue prior to the surveyor's discovery. The resident affected by the deficiency had significant medical needs, including diagnoses of dementia, heart failure, and major depressive disorder. She was severely cognitively impaired, completely dependent on staff for all activities of daily living, and always incontinent of bowel and bladder. Her care plan required that adaptive equipment, such as a functional call light, be provided and maintained. Despite these needs, the call light remained non-functional for an extended period, and there was no documentation or maintenance request indicating that the issue had been previously reported or addressed. Interviews with facility staff, including the Maintenance Supervisor, ADON, and Administrator, revealed that routine checks of call lights were conducted, but the specific non-functioning call light in the resident's room had not been identified or reported through the facility's maintenance request system. The facility's records showed that the call lights in the affected room were only checked on the day of the survey, with no prior checks documented for the preceding period.