Failure to Ensure Resident Had a Functioning Call Light
Penalty
Summary
The deficiency involves the facility’s failure to provide a working call light for a resident with multiple medical conditions and functional limitations. The resident is an older female with neuromyelitis optica, difficulty walking, muscle disorders, lack of coordination, aphasia, depression, anxiety, spinal stenosis, anemia, edema, and other comorbidities. Her BIMS score indicates moderate cognitive impairment, and her care plans document high fall risk, incontinence risk, extensive need for staff assistance with ADLs, and a communication problem related to aphasia. The care plans specifically require that the call light be placed within reach, that staff assess her ability to use it, and that a safe environment be ensured by having the call light in reach. On the survey date, the resident was observed in bed, alert and oriented, with the call light within reach. She reported that she needed to be changed, had been pressing the call light, and that no one had responded. The surveyor observed her pressing the call light and noted that the light at the call light panel did not come on, there was no audible sound, and the light above the door did not illuminate. The resident stated that when she presses the call light staff do not come and that this happens all the time. She also reported that a CNA had said she would return but did not, and that she remained wet and needed to be changed. When the CNA was informed by the resident that the call light was not working, the CNA confirmed that the call light did not activate and stated she would notify maintenance, also acknowledging she had not checked the call light that morning. The Maintenance Director later attempted multiple times to reset and test the call light in the resident’s bed space, confirming that the panel light sometimes came on but there was no audible sound and no light above the door, and at other times the call light did not work at all. The bathroom call light and the call light for the other bed space in the room were found to be functioning. Facility leadership and nursing staff stated that call lights are supposed to be checked every shift and that defective call lights are to be promptly reported and addressed, consistent with facility policies and job descriptions requiring equipment to be maintained in proper working order and hazardous conditions to be reported. Despite these policies, the resident’s primary call light was not functioning as required at the time of the surveyor’s observations and interviews.
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