Failure to Maintain Accessible and Functional Call Light Systems for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents had access to functioning call light systems within reach, as required by their care plans and facility policy. For one resident with a neck fracture, dementia, and no capacity to make decisions, the care plan identified risk for falls and directed staff to keep the call light within reach. During observation, this resident was found awake in bed with a neck brace, and the call light button was on the floor under the bed. The resident stated he did not know where his call light was, and a CNA confirmed its location and acknowledged it should have been placed where the resident could reach it. A second resident, with diabetes, polyneuropathy, retinopathy, gait and mobility abnormalities, and muscle weakness, had an MDS showing intact cognition but required varying levels of assistance with ADLs and transfers. The care plan for this resident, which addressed fall risk, included interventions to keep the call light within reach and to educate/remind the resident to call for assistance with all transfers. During observation, this resident was also found awake in bed with the call light button on the floor under the bed and the cord stuck on the bed frame. The resident reported being unable to reach the call light, and a CNA confirmed the situation and stated the call light should always be within the resident’s reach. A third resident, with a history including a left upper arm fracture, diabetes, muscle weakness, and congestive heart failure, had an MDS indicating mostly substantial/maximal assistance needs for ADLs and supervision or assistance for bed mobility and transfers. The care plan for this resident, addressing fall risk, included instructions to educate/remind the resident to call for assistance with all transfers and to keep the call light within reach. Staff interviews revealed that this resident’s call light “usually gets broken” and that staff would try to fix it, but it would break again. The resident reported feeling annoyed and uncomfortable in the room because the call light had been broken for several days and stated that staff were aware but had not fixed it. Observation with a CNA and the Maintenance Supervisor confirmed the call light system was broken, there was no alternative call system in place, and there was no entry in the maintenance logbook documenting the broken call light. The DON stated she expected residents to have working call lights within reach and acknowledged safety concerns when call lights are not working or not within reach.
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