Failure to Maintain Functional Call Light System in Resident Room
Penalty
Summary
The facility failed to ensure that a resident's call light system was functioning, resulting in the resident being unable to summon assistance when needed. The resident, who had a diagnosis of left below the knee amputation and was dependent on staff for toileting and hygiene, was found to have a non-functioning call light in her room. Both the resident and a surveyor attempted to activate the call light without success, as the indicator light did not illuminate and the room number did not appear on the hallway display. The resident reported being given a tap bell as an alternative, but stated that staff did not always hear it, requiring her to call out for help. Another resident in the same hallway confirmed that the affected resident had called out for help on multiple occasions due to the malfunctioning call light. The facility's policy required that each resident be provided with a functional call system at all times, with calls for assistance to be answered promptly. Despite this policy, the call light in the resident's room remained non-functional, and the issue had not been addressed prior to the surveyor's observation. The administrator was unaware of the ongoing problem until it was brought to her attention during the survey, at which point maintenance was notified. Documentation and interviews confirmed that the call system was not routinely maintained or tested as required, leading to the deficiency.