Failure to Ensure Functioning Call Light System for Resident in Pain
Penalty
Summary
A deficiency was identified when a resident with a history of bone cancer, anal cancer, cognitive communication deficit, and a sacral pressure ulcer was found to have a non-functioning call light in her room. The resident, who was on hospice care and experiencing significant pain, reported that she pressed the call light for assistance but did not receive a response. Upon observation, both the resident and the surveyor attempted to use the call light, but it did not work. The issue was only resolved after the facility administrator was notified and reset the call light by unplugging and re-plugging it, restoring its function. Interviews with facility staff, including a CNA and an LVN, revealed that they were unaware of the malfunctioning call light prior to the surveyor's observation. The CNA stated that the call light was working earlier in the day when she last checked on the resident, and the LVN was also unaware of any issues with the call system. The resident was noted to be in pain and required repositioning, but there was no indication that staff had been alerted to the malfunction before the surveyor's intervention. Facility policy requires that call lights be accessible and functional for residents at all times, including in bed, bathrooms, and bathing areas, and that any problems with the call system be reported immediately with alternative solutions provided until repairs are made. In this instance, the failure to ensure a working call system left the resident unable to summon assistance while experiencing pain, in direct violation of facility policy and regulatory requirements.