Failure to Ensure Resident Call Light Functionality
Penalty
Summary
A deficiency was identified when a resident's call light system was found to be non-functional, preventing the resident from reliably calling for staff assistance. The resident, who required total care with assistance from two staff members and had moderately impaired cognition, reported that her call light worked intermittently. During an observation, the resident demonstrated that pressing the call light did not activate the indicator in the room or above the door. The resident stated that staff were aware of the issue, but she was unsure how long the problem had persisted. A nurse (LVN) confirmed the malfunction during an interview and attempted to troubleshoot the device by replacing the call light cord, which restored functionality. The LVN admitted she had not checked the call light before handing it to the resident and stated she would notify maintenance. The Director of Nursing (DON) and the facility Administrator both acknowledged that staff were responsible for ensuring call lights were operational before providing them to residents, and that maintenance was responsible for repairs. However, the maintenance director indicated that while monthly checks of call lights were performed, they were not documented, and only annual checks were recorded. There was no documentation in the maintenance log regarding the reported malfunction for the relevant period. The facility's policy required staff to report call light problems immediately and to provide alternative solutions until repairs could be made. Despite this, there was no evidence that the malfunction had been reported or that alternative measures were implemented prior to the surveyor's observation. The lack of documentation and failure to verify the call light's functionality resulted in the resident being unable to reliably summon assistance, as confirmed by multiple staff interviews and record reviews.