Failure to Provide Accessible and Functional Call Light System
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, a history of repeated falls, and total dependence on staff for activities of daily living was found without access to a working call light system in her room. Observation revealed that the call light on the wall did not have any means to activate the call system, and the resident confirmed she had no way to call for help except by yelling. The resident's care plan specifically included an intervention for the call light to be within reach due to her fall history. Interviews with the resident and the facility administrator confirmed the lack of an operational call system in the resident's room. The administrator was unaware of the issue and could not provide a reason for the failure. Facility policy required that call lights be accessible and within reach of residents, but this was not followed in this instance.