Deficiency in Resident Call System in Bathrooms
Penalty
Summary
The facility failed to ensure that bathrooms were adequately equipped with a functioning resident call system, as required by §483.90(g). Observations revealed that in four out of seventy-three bathrooms, the emergency pull cords were wrapped around grab bars, rendering them inoperable. This issue was identified in bathrooms located next to the Oasis Kitchen, the Social Worker office, and other unspecified locations within the facility. The inability to activate the emergency pull cords was confirmed through multiple observations conducted at different times. During a tour of the facility, both the Maintenance Technician and the Administrator acknowledged the issue with the emergency pull cords being wrapped around the grab bars. The Maintenance Technician stated that they would ensure regular rounds are conducted to check the emergency pull cords. However, the report does not mention any corrective actions taken at the time of the observations or any immediate plans to rectify the deficiency.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation, the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. Immediate Corrective Action: Call system were unwrapped from the grab bar in the residents bathroom immediately. Identification of other residents potentially affected: Current residents have the potential to be affected; however, based on inspection, no residents were affected. Call light strings in residents bathroom were inspected throughout the units to ensure compliance with resident call system. No other resident call system was identified out of compliance. Measures: On [date], team members were re-educated on ensuring the call system cord is not wrapped around a grab bar. The call system must be adequately equipped to allow residents to call for staff assistance through a communication system. Inservice will be completed for newly hired team members. Monitoring: The Director of Property Management and Maintenance Assistants will complete daily audits for 4 weeks and then weekly for two months to ensure compliance with resident call system standards. The Director of Property Management will report the findings to the Quality Assurance Performance Improvement Committee Monthly for 3 months or until the committee determines substantial compliance.