Failure to Provide Accessible Call Light for Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s room was adequately equipped with an individual call system device, as required by facility policy. Resident C’s clinical record, reviewed on 1/23/26, showed diagnoses including anoxic brain injury, acute respiratory failure with hypoxia, hypercapnia, and anxiety. The resident’s care plan dated 1/13/26 identified a risk for falls and directed that the resident’s call light be placed within reach. During an observation on 1/28/26 at 1:26 p.m., Resident C was found resting in bed with eyes closed and without a call light in place. In the same observation, only a single call cord was present in the room, and it was positioned for the use of the resident’s roommate, leaving Resident C without access to a call system. When CNA 5 entered the room at 1:27 p.m., she confirmed that she did not see a call light for Resident C and stated there should have been a split call cord in the room. At 1:29 p.m., an LPN stated that all residents should have a call light within reach. The Regional Nurse Consultant later provided the facility’s undated “Call Lights” policy, which states that the facility will have a system in place to allow staff to respond promptly to residents’ calls for assistance and that a functioning call light must always be available and accessible to the resident in their room. This deficiency was cited under 3.1-19(u) and related to intakes 2712868, 2713745, and 2718083.
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