Failure to Provide Functioning Call Light for Resident with Communication and Fall Risk
Penalty
Summary
A deficiency was identified when a resident with moderate cognitive impairment, communication difficulties, and a history of impaired vision and fall risk was not provided with a functioning call light. The resident's care plans specifically required that a call light be within reach to ensure safety and facilitate communication with staff. During observation, the call light was found on the floor and not within the resident's reach. Both a CNA and an RN confirmed that the call light was non-functional, with the button stuck and unable to be pressed, and no light or sound was produced when tested. The resident reported that the call light did not work, and staff interviews confirmed the importance of a working call system for residents to request assistance. The maintenance supervisor stated that weekly inspections were conducted and that no issues had been reported for this resident's call light during the last check. However, there was no documentation or notification of the malfunction prior to the surveyor's observation. Facility policy required immediate reporting and replacement of defective call lights, as well as alternative systems and hourly safety checks if the primary system was inoperable, but these measures were not documented as being implemented for this resident.