Failure to Maintain Functional Call Light System for Residents
Penalty
Summary
The facility failed to ensure a fully functioning call light system was available and operational for all residents, specifically affecting four residents out of eighteen reviewed. Multiple residents reported that their call lights were either not working properly or not being answered in a timely manner. Observations confirmed that in several cases, the call light would activate inside the resident's room but would not trigger the hallway indicator to alert staff, and in some instances, the call light remained on even after staff attempted to turn it off. Additionally, some residents reported that their call lights were placed out of reach, preventing them from calling for assistance when needed. Interviews with residents revealed ongoing issues with the call light system, including long wait times for staff response and instances where no one responded at all. One resident reported waiting approximately two hours for assistance, while another stated that the call light system in her room frequently did not work and was often out of reach. Family members and roommates corroborated these accounts, noting repeated problems with the call light system and the need for residents to call out for help when the system failed. Facility staff, including the Director of Facilities and the DON, acknowledged awareness of the call light system's deficiencies. The facility had previously attempted to use cell phones as part of the system, but these were not functioning properly and were discontinued. The monitoring screen for call lights had also been placed in a location not visible to staff at the nurse's station until recently. Work orders confirmed repeated maintenance requests for the malfunctioning call light system in affected rooms, but issues persisted, resulting in residents' needs potentially going unmet.