Failure to Provide Functioning Call Light System at Bedside
Penalty
Summary
The facility failed to ensure that a resident had access to a functioning call light system at the bedside, as required for requesting staff assistance. During observation, it was noted that the call light device available to the resident was missing the push button component, leaving only the outer casing. The resident, who was nonverbal, dependent on staff for all activities of daily living, and had significant medical conditions including quadriplegia, tracheostomy, and a stage 4 pressure ulcer, was unable to use the call system to summon help. Interviews with facility staff, including the Administrator, DON, CNAs, LVN, HR/Payroll Director, and Maintenance Director, revealed that none were aware that the call light in the resident's room was nonfunctional prior to the surveyor's observation. Staff acknowledged that the expectation is to check call lights regularly and ensure they are within reach and operational for all residents. The Maintenance Director reported conducting weekly checks of call lights and keeping spare parts available, but there was no documentation of a broken call light for this resident in the maintenance binder. Record review confirmed that the facility's policy requires each resident to have a means to call staff for assistance from their bed, and that the call system must remain functional at all times. Despite these policies and routine checks, the deficiency occurred due to a lack of awareness and failure to identify and address the nonfunctional call light for a resident with severe impairments and high care needs.