Deficiency in Call Light System Leads to Delayed Resident Assistance
Summary
The facility was found to have a significant deficiency in its communication system, specifically the call light system, which was not functional in several halls, including halls 100, 300, 400, and 500. This deficiency was identified through observations, interviews, and record reviews. On multiple occasions, it was noted that call lights in resident rooms and bathrooms were not working, leaving residents without a means to call for assistance. This lack of a functional call system was observed to cause delays in assistance, with residents reporting feelings of abandonment and fear due to the inability to reach staff when needed. Several residents were directly affected by this deficiency. For instance, a resident with paraplegia and PTSD reported feeling abandoned as no staff checked on her overnight, and her call light was non-functional. Another resident, who required assistance with a G-Tube, experienced delays of over an hour at night to receive help. Additional residents reported waiting for extended periods, sometimes over two hours, for assistance with essential needs such as repositioning, changing, and managing medical equipment like a CPAP machine. These delays were attributed to the non-functional call light system, which was not audible at the nursing stations, and the lack of visibility of rooms from these stations. The facility's grievance logs and interviews with residents further highlighted the impact of the non-functional call light system. One resident had previously filed a grievance about unanswered call lights and facility phones, with no resolution noted. Observations confirmed that call lights were not sounding at nursing stations, and in some cases, lights above resident rooms were not illuminating, exacerbating the issue. This situation led to the identification of an Immediate Jeopardy, indicating a severe risk to resident safety and well-being due to the facility's failure to provide a reliable means for residents to communicate their needs to staff.
Removal Plan
- Conduct in-service training for all staff on the importance of resident checks and proper use of the call light system.
- Ensure all call lights in resident rooms and bathrooms are fully functional. A certified electrician will repair any non-functional lights.
- Conduct checks of call light systems to ensure ongoing functionality.
- Inform residents and their families about the steps being taken to address the identified issues and ensure their safety and well-being.
- Conduct audits for compliance with the above actions.
- Any noncompliance or issues identified during audits must be reported to the DON and Administrator for corrective action.
- Maintain thorough documentation of all corrective actions, training sessions, maintenance checks, and communication with residents and families.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Surveyors found that multiple residents had non-functional call lights in their bathrooms and bathing areas, with some call lights failing to activate outside the room and others not signaling at the nurses’ station. A DOM and an RN confirmed these failures during testing, and a maintenance staff member reported that malfunctioning call lights were an ongoing issue. Review of work orders showed that these specific call light problems had not been reported, despite facility policy requiring staff to immediately report call system issues and ensure residents have access to a working call system.
The facility failed to maintain a call light system that stayed active until staff responded and to ensure timely responses to resident calls. A resident’s daughter reported that her mother waited an extended time for assistance despite using the call light and that she repeatedly observed CNAs not performing 2-hour checks as expected. In another case, a surveyor tested a resident’s call light and found it automatically reset after about 16 minutes, requiring the resident to reactivate it, with staff not answering until several minutes after the initial activation. Maintenance staff confirmed the automatic reset feature, and a staff member acknowledged that call lights were not answered promptly and that residents had complained, contrary to the facility’s call light policy.
Surveyors found that three residents with dementia, impaired cognition, mobility limitations, and other comorbidities did not have call lights within reach while in bed. In one case, a resident’s call light was attached to a privacy curtain across the room; in another, both call lights in a shared room were attached to the roommate’s bed, leaving the other resident without access. A third resident’s call light was wound up over the actuator box near a recliner and could not be reached from the bed, and the bed controller was on the floor out of reach. These conditions occurred despite a facility policy stating that call light or bell access will be within reach as a method for residents to communicate needs to staff.
Surveyors found that staff failed to keep call lights within reach for two cognitively impaired, ADL-dependent residents who were care planned as fall risks. In one case, a resident seated in a Broda chair had the call light lying on the floor beside the bed, despite a care plan requiring it to be within reach and a sign to prompt use; a CNA confirmed it was not accessible and noted a loop on the cord intended for the resident’s wrist due to blindness. In another case, a resident lying in bed had the call light positioned behind a refrigerator, also out of reach, which a CNA verified. These observations showed the facility did not follow its own policy requiring call lights to be easily reachable when residents are in bed or confined to a chair.
Surveyors found that two residents did not have their call lights within reach as required by their care needs and the facility’s nurse call policy. One resident with MS, lack of coordination, and epilepsy was observed in a wheelchair with the call light on the floor and no Velcro strap attached as specified in the care plan, and repeated attempts to use the call light with the chin caused it to fall from the hand. Another resident with ALS, respiratory failure with hypercapnia, and Parkinson’s disease was observed in bed with the call light placed on a nightstand out of reach until an LPN moved it onto the resident’s stomach. Facility leadership confirmed the expectation that residents be provided with accessible call lights and appropriate assistive tools after care and ADL assistance.
A resident with multiple chronic conditions was unable to reliably use the call system in the bathroom due to a known malfunction, resulting in staff providing a handheld bell as an alternative. Facility staff confirmed that a specific issue with the bathroom call system prevented signals from reaching the nurses' station, and resident council minutes documented ongoing concerns about call light response.
Non-Functional Call Lights in Resident Bathrooms and Bathing Areas Not Reported or Repaired
Penalty
Summary
The deficiency involves the facility’s failure to ensure that resident call lights in bathrooms and bathing areas were functional and operating as required. During an observation period with the Director of Maintenance (DOM), call lights for four residents were tested and found not to activate outside the rooms. For two of these residents, the call lights did not light up outside the room when tested, and the DOM stated he thought the light bulbs had gone bad. For the other two residents, their call lights did not activate outside the room and also did not ring at the nurses’ station when pressed, which was confirmed by both a Registered Nurse (RN) and the DOM. Further interviews and record reviews showed that these non-functioning call lights had not been reported through the facility’s work order system. A Maintenance Assistant stated that non-working call lights were an ongoing issue and that he was sure some were outstanding. Review of electronic work orders for the relevant period did not show any entries for the rooms where the call lights were found to be non-functional. The facility’s policy on call lights states that staff are educated on proper use of the call system, including ensuring resident access, and that staff will report problems with call lights or the call system immediately to a supervisor and/or maintenance director and provide immediate or alternative solutions until the problem can be remedied. This policy was not followed for the four residents identified in the complaint investigation.
Failure to Maintain Functioning Call Light System and Timely Response to Resident Calls
Penalty
Summary
The deficiency involves the facility’s failure to ensure a functioning call light system that remained active until staff responded, affecting resident bathrooms and bathing areas and potentially all 37 residents. A resident’s daughter reported via email that her mother’s visitor had to ask someone in the hallway to check on the resident after waiting a long time for a response to the call light; the person who checked stated the resident was dry, but the visitor could smell urine and knew this was not accurate. The resident was later taken to the bathroom by others, including a physical therapist, who stated that because the resident was not bearing weight on her legs, they would not be able to continue taking her to the bathroom. The daughter expressed concern that her mother would be incontinent of urine and stool and remain so for hours before being changed, and that even when calling out for help, it took an extended time for assistance to arrive, if at all. She also stated that CNAs were supposed to check residents every two hours but did not, and that she had observed this pattern on each of her visits. During the survey, a state surveyor activated a resident’s call light and observed that it remained active for 16 minutes and 15 seconds before resetting, requiring re-activation by the resident. The surveyor activated the call light at 2:22 P.M., again at 2:33 P.M. while it was still red, and again at 2:38 P.M. after the red light disappeared, with staff not answering until 2:40 P.M. The CNA who responded confirmed she was alerted via walkie talkie but could not state when the call light was first activated. The maintenance director and assistant verified through the call system computer that the call light had been on for 16 minutes and 15 seconds before resetting and then was activated again, confirming the system automatically resets after that time. An anonymous staff member also confirmed that call lights were not answered timely and that residents had voiced concerns. The facility’s call light policy stated that call lights would be silent only after residents’ needs were met, which was not followed in these instances.
Failure to Keep Call Lights Within Reach for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure resident call lights were within reach for multiple residents, contrary to facility policy stating that call light or bell access will be within reach as a method for residents to communicate needs to staff. One resident with dementia, depression, high blood pressure, impaired cognition (BIMS score of 3/15), and a self-care deficit related to language barrier and impaired mobility was observed lying in bed asleep with the bed positioned against the wall while the call light was attached to the privacy curtain across the room, out of the resident’s reach. A RN confirmed that this resident’s call light was attached to the privacy curtain across the room rather than being accessible from the bed. Another resident with Alzheimer’s disease, depression, anxiety, high blood pressure, impaired cognition (BIMS score of 5/15), functional incontinence, impaired communication related to dementia, and impaired mobility requiring staff assistance was observed sleeping in bed with no call light in reach; both call lights in the room were attached to the roommate’s bed. The RN confirmed that this resident’s call light was attached to the roommate’s bed and not within reach. In a separate observation, a third resident’s call light was found wound up over the call light actuator box near the recliner, not reachable from the bed, and the bed controller was on the floor at the foot of the bed, also out of reach. These observations showed that three residents reviewed for call light use did not have accessible call systems as required by facility policy.
Failure to Ensure Call Lights Were Accessible to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain a call light system that was readily accessible to residents in accordance with its policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. For one resident with Alzheimer’s disease, schizophrenia, and major depressive disorder, the care plan identified a risk for falls and included interventions to ensure the call light was within reach and a sign was in place to remind the resident to use the call light for assistance. The quarterly MDS showed this resident was moderately cognitively impaired and dependent on staff for ADLs. On two separate observations the resident was seated in a Broda chair next to the bed while the call light was found on the floor beside the bed, not within reach. A CNA confirmed the call light was not accessible and explained that a loop was placed around the call light cord to go around the resident’s wrist because the resident was blind. A second resident, admitted with dementia, chronic kidney disease, and diabetes mellitus, also had a care plan identifying fall risk with an intervention to ensure the call light was within reach. The quarterly MDS indicated this resident was severely cognitively impaired and dependent on staff for ADLs. During observation, this resident was lying in bed while the call light was located behind the refrigerator, out of the resident’s reach. A CNA verified that the call light was not accessible to the resident. These findings were identified during the course of a complaint investigation and showed that, for two of three residents reviewed for call light accessibility, the facility did not ensure call lights were positioned so residents could use them as required by facility policy and care plan interventions.
Failure to Maintain Accessible Call Lights for Two Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure that call lights were within reach of residents who were able to use the call light system. For one resident with multiple sclerosis, lack of coordination, and epilepsy, the care plan specified that the resident could use the call light when it was placed in the right hand with a Velcro strap attached to the call light cord and wrapped around the hand, allowing activation with the chin. During observation, this resident was seated upright in a wheelchair with the call light lying on the floor out of reach. A CNA confirmed the call light was out of reach and placed it in the resident’s right hand, but there was no Velcro strap attached. Subsequent observation showed the resident making multiple attempts to press the call light with the chin, but the device fell from the resident’s grasp onto the floor, again without any Velcro strap visible. An RN unit manager and a psychiatric nurse practitioner both verified that the call light had been out of reach on arrival and that the Velcro strap, which was supposed to be in use, could not be located in the room. A second resident, with diagnoses including ALS, respiratory failure with hypercapnia, and Parkinson’s disease, was observed in bed with the call light placed on the bedside nightstand, out of reach. An LPN confirmed that the call light was not within the resident’s reach and then moved it onto the resident’s stomach. In interviews, the DON and the Administrator confirmed that the facility’s expectation was that residents returning to their rooms after care and ADL assistance would be provided with a call light using the tools required per their individual care plans. Review of the facility’s Nurse Call System Policy stated that the facility would provide a means for residents to make staff aware of care needs at all times, including use of modified devices when needed. The observations and interviews showed that, for these two residents, the call light system was not maintained within reach or in the manner required by their care plans and facility policy.
Failure to Maintain Functional Call System in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that resident call systems were functioning properly in bathrooms and bathing areas, as evidenced by the experience of one resident who reported that her call light was not answered on multiple occasions. The resident, who had multiple diagnoses including chronic respiratory failure, diabetes, dementia, and other serious conditions, stated that staff provided her with a handheld bell due to the malfunctioning call system. Medical record review and interviews confirmed that the resident required assistance with activities of daily living and had ongoing health concerns. Observation and interviews with facility staff, including the Administrator and Maintenance Director, revealed a known issue with the call system in double rooms with shared bathrooms. Specifically, if a metal lever or switch in the bathroom was left partially engaged, the call light above the resident's bed would illuminate but would not send a signal to the nurses' station or outside the room. Review of Resident Council meeting minutes also documented ongoing resident concerns about call light response. There was no facility policy specifically addressing call lights, though staff were expected to respond in a timely manner.
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