Failure to Ensure Functioning Call Light System for Dependent Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide a functioning call light system for one of four sampled residents. The resident, who had diagnoses including respiratory failure, tracheostomy, and muscle wasting, was assessed as having moderately impaired cognitive skills and was dependent on staff for all personal care activities. On the date of the incident, the resident was observed attempting to use the call light to request assistance for incontinence care, but no staff responded. Upon investigation, it was found that the call light cord was partially disconnected from the wall, rendering it nonfunctional. The resident expressed a need for assistance due to discomfort in the perineal area. Staff interviews confirmed that the call light was not properly connected, preventing it from alerting staff to the resident's needs. Facility staff, including an LVN, the Director of Staff Development, and the Director of Nursing, acknowledged the importance of ensuring call lights are plugged in, working, and within reach, especially for residents who cannot communicate verbally. Review of facility policy indicated that a working call system should be available to enable residents to alert nursing staff promptly from their beds.