Failure to Provide Resident with Functional Call Light Access
Penalty
Summary
A deficiency was identified when a resident was found without access to a functional call light system. The resident, who has diagnoses including type 2 diabetes, chronic kidney disease, reduced mobility, muscle weakness, and a history of repeated falls, reported that her squeeze call light had not worked for over a week. She was provided with a manual hand bell as an alternative, but stated that when she used it, staff did not respond, leaving her to wait until she could visually locate someone for assistance. During observation, the call light did not activate the hallway notification system, and the hand bell was only faintly audible in the hallway, with no staff present nearby. The resident expressed fear and concern about her inability to summon help, particularly as she could not get back into bed independently. Interviews with facility staff, including an OT, LPN, CNA, maintenance assistant, and the ADON/DON, revealed a lack of awareness regarding the non-functional call light. Staff stated that all call lights should be operational and that any issues would be addressed promptly, but the maintenance assistant was not aware of any outstanding work orders. Upon testing, the maintenance assistant determined that the call light device functioned, but the resident may not have had the strength to operate it effectively. The facility did not provide a policy regarding call lights.