Failure to Provide Functional Call Light System for High-Risk Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, high fall risk, and significant physical limitations did not have access to a functional call light system in her room. The resident, who was dependent on staff for transfers and had a history of falls, was observed to lack a working call light, which was confirmed through direct testing by the Director of Nursing (DON). The call light failed to activate at the room wall panel, hallway indicator, or nurse's station, while the roommate's call light was functional. The resident's care plan did not include interventions for a call system, and her fall risk assessment indicated a high risk. Interviews revealed that there was no work order for repair of the call light, no maintenance log for checking call light functionality, and no maintenance staff employed at the time. The Administrator, who was responsible for maintenance, acknowledged the lack of routine checks and explained that the call system was older and sometimes required manual resetting. The facility's policy required that each resident have a functional call system at all times, and alternative communication means should be documented in the care plan if the resident could not use the standard system. The deficiency was identified through observations, interviews, and record review.