Failure to Ensure Functioning Call Lights for Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights were functioning properly for two residents who were dependent on staff for care and had significant cognitive and physical impairments. For one resident with Alzheimer's disease, dementia, and other chronic conditions, both the wall call light button and the handheld device were missing, rendering the call light non-functional. This resident was assessed as severely cognitively impaired but capable of using the call light, and the care plan required the call light to be within reach. A CNA confirmed the call light was not working for this resident. Another resident, who had hemiplegia, diabetes with nephropathy, blindness in one eye, and cognitive communication deficits, also had a non-functioning call light. This resident was dependent for all care and at risk for falls and incontinence, with a care plan intervention to ensure the call light was within reach and to encourage its use. Observation and staff interview confirmed the call light did not work when pressed by the resident. Facility policy required call systems to be accessible and for staff to report and address any problems immediately, but this was not followed in these cases.