Resident Left Without Accessible Call Light in Bathroom
Penalty
Summary
A resident with multiple diagnoses, including pneumonia, heart failure, COPD, atrial fibrillation, gait abnormalities, anxiety, unsteadiness, dependence on supplemental oxygen, and osteoarthritis, was placed in the bathroom by staff and left without access to a functioning call light. The resident reported that the bathroom call string was broken and lying on the ground, making it inaccessible. She waited on the toilet for an extended period without staff checking on her and ultimately used her phone, which she keeps on a lanyard, to call 911 for assistance. The police responded after 911 was unable to reach the facility by phone, and the resident was found still on the toilet, appearing anxious and expressing a fear of falling and a need for assistance with transfers. Staff interviews confirmed that the call light was not provided to the resident and that the broken call string was not reported or noticed by the staff responsible for her care. The facility's policy requires that call lights be accessible to residents at each toilet and that staff report any problems with the call light system immediately. The administrator confirmed that the call light was broken and that the resident was left in the bathroom without a means to call for help, despite being assessed as a fall risk.