Inaccessible Call Light in Resident Bathroom
Penalty
Summary
The facility failed to ensure that each resident bathroom was adequately equipped with a functioning call system accessible to residents, as required by federal regulations. During observations, surveyors found that the call cords in a resident's bathroom were wrapped around the grab bar, rendering the call system inaccessible and nonfunctional in its current state. The Director of Maintenance confirmed that the call light would not function properly when wrapped around the grab bar and had to manually unwrap and test it to restore functionality. Interviews with staff revealed gaps in the facility's procedures for checking call lights. The Social Service Assistant, who was assigned as the Guardian Angel for the resident, stated that her checks only included verifying the presence and physical condition of the call light, not whether it was wrapped around the grab bar or if it was operational. This lack of thoroughness in daily checks contributed to the deficiency, as the inaccessibility and improper placement of the call cord went unaddressed until identified by surveyors.
Plan Of Correction
On , the call light in the bathroom of # was unwrapped from the grab bar and assessed to be functional by the maintenance director. On , the Maintenance Director conducted a quality review of the call lights in resident rooms and bathrooms to ensure that they were functioning properly. By , current staff were educated by the Staff Development Coordinator on F919 with an emphasis on ensuring call lights were unwrapped from the grab bar and appropriately functioning. As part of a systematic change, the Nursing Home Administrator updated the Angel Rounds form on to include proper call light functioning. NHA/designee will conduct quality monitoring of 10 call lights weekly x 4 weeks and then 20 call lights monthly x 2 months to ensure that call lights are properly functioning. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.