Failure to Maintain Functional Call Light System for Resident Safety
Summary
Multiple residents were observed to have non-functioning or unreliable call light systems in their rooms, which impeded their ability to request assistance from staff. One resident, who had intact cognition and required assistance with most activities of daily living, reported that their call light did not work and that maintenance had attempted repairs several times without success. This resident resorted to using a hotel-like bell, which was not audible when the door was closed, and staff did not respond to the bell on at least one occasion. Another resident, who was wearing a sling and used a wheelchair, also relied on a hotel-like bell and expressed uncertainty about whether the call lights in their room and bathroom worked. This resident reported having to wait longer for staff assistance and sometimes asked staff to leave the bathroom door open so they could call for help verbally. A third resident, who had a tracheostomy and communicated by typing on a cell phone, also used a hotel-like bell and reported delays in receiving assistance after calling for help. Staff interviews revealed that the call light system was dependent on a wireless network, which frequently lost signal, and that pagers, which were part of the system, were not consistently used or functional. The call light alert box at the nursing alcove displayed incorrect dates and times, and staff were unable to determine how long it took to respond to calls or if someone else had turned off the alert. Maintenance staff confirmed that the system was not hard-wired, was reliant on WiFi, and that no regular audits were conducted to ensure functionality; instead, they responded only to complaints. Facility policy required that call lights be accessible and functional at each resident's bedside, toilet, and bathing facility, and that staff be educated on their use. However, observations and interviews indicated that the system did not consistently alert staff, alternative bells were not effective, and staff were not always aware of or using all components of the system. Documentation from the system manufacturer recommended monthly testing of personal help buttons, but maintenance staff did not perform routine checks. The deficiency was further evidenced by the lack of hallway or in-room call light indicators and the facility's reliance on resident complaints to identify issues.
Penalty
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