Failure to Maintain Functional Call Light System for Dependent Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure a functioning call light system for a resident. The resident had been admitted with diagnoses including traumatic hemorrhage of the cerebrum, muscle weakness, and lack of coordination, and an MDS assessment documented moderately impaired cognition and dependence for rolling and chair/bed-to-chair transfers. During observation, the resident was seated in a wheelchair at the foot of the bed, facing away from the door, and repeatedly yelled, “Can I go to the bathroom,” 16 times. The call light button was taped on top of the bottom bed rail next to the resident. When the resident pressed the call light button, the call light bulb outside the room did not illuminate and there was no audible sound outside the door. A CNA confirmed that the call light did not activate any light or sound and stated they would call maintenance. Maintenance staff later entered the room and stated the light bulb outside the door was not working and that they had not previously received a report that the resident’s call light needed to be checked. The facility’s policy on the call system stated that the facility would maintain a communication system to allow residents to call for staff assistance from rooms and toileting/bathing areas, and that any defective call alert system would be reported to maintenance for immediate repair.
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