Failure to Provide Functioning Call Light System for Resident with Mobility Impairment
Penalty
Summary
A deficiency was identified when a resident with paraplegia and other mobility limitations did not have access to a functioning call light system in his room. The resident, who was cognitively intact and at risk for falls, reported that his call light had not worked since he moved into his current room. He stated that he informed staff about the issue when he first moved in, but the problem was never addressed. As a result, the resident had to self-transfer to his wheelchair and go down the hall to find staff whenever he needed assistance. Multiple staff members, including a CNA, LPN, and maintenance staff, confirmed through observation that the call light did not function or illuminate outside the room as required. A review of the facility's maintenance log showed no entries regarding the malfunctioning call light for this resident, despite facility policy requiring staff to notify maintenance and document such issues. The Director of Nursing confirmed that staff should have documented the problem and notified maintenance, and acknowledged that the resident was capable of using the call light. The lack of a functioning call system in the resident's room was not addressed according to facility procedures, resulting in the deficiency.