F0558

D

Failure to Keep Call Light Within Reach for Resident in Pain

Pasadena, California Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The facility failed to ensure a resident’s call light was within reach so the resident could request assistance and pain medication. The resident had diagnoses including COPD, hereditary and idiopathic neuropathy, and back muscle spasms, and was dependent on staff for all ADLs such as eating, toileting hygiene, bathing, dressing, and personal hygiene. The resident’s MDS dated 3/13/2026 documented that she received both scheduled and PRN pain medications and had experienced moderate pain within the last five days. Her care plans for acute left arm/shoulder pain and for potential excessive weakness, tiredness, weight loss, pain, and depression directed staff to anticipate her need for pain relief, respond immediately to any complaint of pain, and provide pain medication as ordered. Physician orders dated 2/23/2026 included Tramadol 50 mg via PEG tube every six hours as needed for moderate to severe pain.

On 3/4/2026 at 10:40 AM, during observation and interview in the resident’s room, the resident stated she was in a lot of pain with a pain level of 10/10 and was observed looking for her call light, stating she did not have one. The call light was then observed on the side rail behind a trash bag, out of the resident’s reach, and the resident was observed yelling for the nurse. In interviews, the RN Supervisor stated it was not acceptable for the call light to be hidden behind a trash bag because the resident would not be able to ask for assistance when needed and receive proper treatment for her pain. The DON stated the call light should be within the resident’s easy reach and not behind a trash bag, and confirmed that per the facility’s “Answering the Call Light” policy, revised 3/2021, when a resident is in bed or confined to a chair, the call light must be within easy reach.