Neglect Related to Call Light Response for Dependent Resident
Penalty
Summary
Surveyors identified a deficiency related to neglect when a resident with quadriplegia reported that staff were turning off their call light from the nursing station without responding to their needs or requests. A facility Concern Form dated 8/4/25 documented that the resident alleged staff turned off the call light from the desk without completing the requested task. During the facility’s internal inquiry, a nurse admitted to turning off the resident’s call light from the nursing station without going to the room to determine why the call light had been activated. During the survey on 2/11/26, the resident was observed in bed using a specialized, breath-activated call light designed for individuals with limited or no motor skills. In an interview at that time, the resident stated that staff were still turning off the call light from the nursing station without coming to the room. The resident explained they could tell the call light was deactivated from the desk because the hallway bell would stop sounding and no one would enter the room. The resident also reported that, in the past, the Administrator had been present in the room, activated the call light, and witnessed staff deactivating it from the nursing station without checking on the resident. The resident’s clinical record showed diagnoses including quadriplegia, peripheral vascular disease, chronic pain, pressure ulcers, neuromuscular dysfunction of the bladder, presence of a suprapubic catheter, and urinary tract infections. The facility’s abuse policy defined neglect as the failure of the facility or its employees to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress.
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