Failure to Provide Functioning Bedside Call Light System
Penalty
Summary
The facility failed to provide a functioning call light system at the bedside for a resident who used a wheelchair and required moderate assistance with lower body dressing. The resident reported that upon moving into the room, maintenance staff informed him there was no place to hook up a call light, and he never received one during his stay. Instead, the facility provided a bell, which the resident could not always locate and which staff could not hear due to the room's location at the end of the hallway. On at least one occasion, the resident was unable to get out of bed and had to yell for help because no call light was available. Observations confirmed there was no call light plugged in above the bed, and the resident and staff both confirmed that a call light had never been provided at the bedside. Further investigation revealed that the maintenance supervisor was aware of the missing call light and attributed it to the room's previous configuration as a single room. Email documentation showed delays in ordering and receiving the necessary call light equipment, with no evidence of follow-up between July and September. When a call light was eventually installed, it did not function properly: pressing the button did not activate the light above the resident's door or produce a sound at the nurses' station, and the alternative bell system remained ineffective. Facility policy required that call lights be plugged in, functioning, and accessible to residents at all times, but this was not followed in this case.