Failure to Provide Accessible and Functional Call Light for Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple complex medical conditions, including an indwelling urethral catheter, hematuria, difficulty walking, type II diabetes mellitus, obstructive and reflux uropathy, benign prostatic hyperplasia, cerebral infarction, and Parkinson's disease, was found without a functioning call light within reach. The resident required significant assistance with activities of daily living and was dependent for toileting hygiene. During observation, the resident was seen in pain and attempted to use the call light, which was not operational. The call bell was found on top of the bedside drawer, out of the resident's reach. Interviews with staff confirmed that the call bell should be accessible to residents at all times to ensure timely assistance, especially in emergencies. The maintenance supervisor was unaware of how long the call light had been nonfunctional, and maintenance logs showed previous notifications about the issue. Facility policy requires that call lights be accessible to residents when in bed, but this was not followed in this instance, resulting in the resident's inability to summon help when needed.