Deficient Call Light System Leads to Delayed Resident Assistance
Penalty
Summary
The facility failed to ensure that the call light system was functioning properly throughout the building, resulting in staff being unable to hear or see call light alerts when away from the centralized nurse's station. Observations revealed that the audible alarm for the call light system was only present at the nurse's station and was not audible down the hallways. The visual indicators for activated call lights were also obstructed by the building's layout, making it difficult for staff to identify which rooms required assistance and in what order. The call light system did not provide information on how long a call had been active or which resident had called first. Multiple residents reported significant delays in staff response to call lights, with some waiting up to two hours for assistance with pain management, toileting, or urgent medical needs. One resident described an incident where her roommate experienced difficulty breathing and had already activated the call light, but staff did not respond until additional efforts were made to attract attention. Another resident recounted waiting over an hour for help after an incontinence episode, and a respiratory therapist documented an instance where a resident in need of immediate medical attention was not attended to because the call light alarm was not heard. Internal audits and grievance records confirmed a pattern of delayed call light responses, with documented response times ranging from one minute to over an hour and multiple grievances filed regarding long waits for care. Staff interviews corroborated these findings, with CNAs and LPNs stating that the call light alarms were difficult to hear or see from various locations in the facility, and that the system did not indicate which resident had been waiting the longest. The facility's policy required call lights to be accessible and to relay alerts directly to staff or a centralized location, but the current system did not meet these requirements due to technological and structural limitations.