Failure to Develop and Implement Person-Centered Care Plans During Call Light System Outage
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for five residents when the call light system was not operational. Instead of a functioning call light system, residents were provided with handheld bells, but there was no individualized care planning to address each resident's ability to use these devices or their specific needs. The Director of Nursing confirmed that no such care plans were created for residents using handheld bells during the period when the call light system was inoperative. Observations and interviews revealed that residents had varying degrees of cognitive and physical abilities, which affected their capacity to use the handheld bells. For example, one resident with a history of falls and intact cognition refused to use the bell, preferring to call out for help. Another resident with moderate cognitive impairment and a recent fall reported delays in staff response when using the bell. Residents with significant cognitive or physical limitations, such as those with advanced dementia or who were rarely understood, often had the bell placed out of reach or were unable to use it effectively. Staff interviews corroborated that the call light system had been nonfunctional for an extended period, and that the use of handheld bells posed risks, especially for residents unable or unwilling to use them. The facility's own policy required comprehensive, person-centered care plans with measurable objectives and timetables, but this was not followed for residents affected by the call light system failure.