Failure to Provide Functioning Call Light and Alternative Communication
Penalty
Summary
The facility failed to ensure that a resident's call light was functioning properly, resulting in the resident being unable to summon assistance when needed. The call light in the resident's room did not illuminate outside the doorway when pressed, although it did activate the panel at the nurse's station. This malfunction persisted from a Saturday through the following Tuesday, during which time the resident experienced an episode of urinary incontinence because staff did not respond to his call for assistance to the bathroom. The resident, who had a history of pneumonia and lack of coordination, was unable to get up independently to use the bathroom. Interviews with staff revealed that when a call light was broken, the issue was logged for maintenance, but repairs were delayed over weekends. Staff were unaware of alternative methods for residents to call for help when the call light was not working, and the resident was not provided with a hand bell or other means of communication during the outage. Facility policy required that an alternative method, such as individual bells, be provided if the call light system malfunctioned, but this was not implemented. Maintenance records confirmed the call light was reported broken, and an incorrect bulb replacement further delayed the repair.