Failure to Maintain Functional Lighting in Resident Room
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public by not ensuring that the bedside and overhead lights in one resident's room were operational for at least 30 days. The affected resident, a 75-year-old male with peripheral vascular disease, chronic kidney disease, a left below-the-knee amputation, and diabetes, required total assistance for transfers and mobility and had moderate cognitive deficits. Observations confirmed that both the overhead and bedside lights in his room were not working, and the resident reported that the lights had been out for five months, impacting his ability to see at night and during care activities. He stated that he had complained to nursing staff but felt ignored. Interviews with staff, including the DON, Administrator, RN, and CNA, revealed that the issue had been reported but not addressed due to the absence of a maintenance director. The facility had been relying on maintenance support from a sister facility, and work orders were maintained manually, but the log could not be located. The interim Maintenance Director was unaware of the issue and had not received a work order. Staff acknowledged the importance of functional lighting for providing care and noted that the lack of lighting had not resulted in any reported negative outcomes, but it did diminish the resident's quality of life.