Failure to Ensure Accessible and Functional Call Light System for Residents
Penalty
Summary
The facility failed to ensure that a working call system was available and accessible to residents in their bathrooms and bathing areas, resulting in six residents being unable to reliably summon assistance. Multiple residents experienced inoperable or inaccessible call lights, with some call buttons found on the floor, out of reach, or missing entirely. In one instance, a resident's call light was removed due to safety concerns, but no alternative means of communication was provided, and the replacement manual call bell was not within reach. Staff interviews confirmed that issues with call lights were not always reported or documented, and maintenance logs were incomplete. Residents affected by this deficiency had varying degrees of cognitive and physical impairment, including diagnoses such as monoplegia, muscle weakness, dementia, multiple sclerosis, and chronic obstructive pulmonary disease. Some residents had intact cognition, while others were severely cognitively impaired, increasing their vulnerability when call systems were not accessible. One resident was left in soiled clothing and bedding for extended periods due to unanswered call lights, and another waited over an hour for pain medication because the call system failed to alert staff. Observations and interviews revealed that staff were sometimes unaware of missing or inaccessible call lights, and there was a lack of consistent communication between nursing and maintenance regarding repairs. Facility policy required call devices to be within reach and prompt reporting of defective equipment, but these procedures were not consistently followed. Rounds were supposed to include checks for call light accessibility, but this was not reliably implemented, contributing to the deficiency.