Failure to Maintain Call Light Accessibility Resulting in Delayed Pain Management
Penalty
Summary
A deficiency occurred when a resident with a history of pain, osteoporosis, difficulty walking, and muscle atrophy was unable to access her call light and bedside table during the night. The resident, who was cognitively intact, reported that she experienced severe leg pain while in bed and was unable to summon assistance because the call light was out of reach. She attempted to call out for help, but her voice was too soft to be heard, and she did not have a roommate to assist her. As a result, she remained in pain for several hours until the morning, when she reported the incident to a nurse. Documentation showed that the resident had a PRN order for Tramadol for pain, but the nurse who administered the medication in the morning did not document the resident's pain level as required by facility policy. Interviews with staff confirmed that the call light and bedside table were out of reach during the night, and that this information was communicated among staff members. Facility policies required that call lights be accessible at all times and that pain assessments be documented every shift, but these procedures were not followed in this instance.