Non-Functional Call Light System for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with hemiplegia, generalized muscle weakness, dysphagia, and severely impaired cognition was found to have a non-functional call light system. The resident was dependent on staff for personal hygiene and required significant assistance for repositioning in bed. The care plan for this resident specified that the call light should be within reach and that staff should explain its use for requesting assistance. However, during multiple observations, the resident pressed the call light several times, but the indicator light outside the room did not activate, confirming the system was not working. Interviews with facility staff, including a CNA and an RN, confirmed that the call light was not functional and that it should always be operational to allow residents to request help. The facility's policy required a mechanism for residents to promptly communicate with nursing staff, but this was not provided in this instance. As a result, the resident was unable to call for staff assistance or express needs, placing him at risk for delayed care or accidents.