Failure to Provide Accessible and Functional Call Light for Nonverbal Resident
Penalty
Summary
The facility failed to ensure that a resident with a tracheostomy, hemiplegia, and no speech had access to a functioning call light system. The resident, who uses a communication board and is alert and oriented, was observed with the call light string on the floor, out of reach, and the call light itself was not working—there was no illumination or audible sound when activated. The resident communicated via the board that the call light had not worked for a week. Upon inspection, it was found that the call light did not display any indication at the nursing station panel. Staff investigation revealed that the call light system in the resident's room would not function if the bathroom call light switch was in the middle position. Maintenance staff stated they were unaware of how the bathroom switch was moved, as the resident does not use the bathroom independently. Facility policy requires that residents have access to a functioning call light system that is easy for them to use and placed within reach, but this was not followed in this instance.