Failure to Maintain Functional Call Light System in Resident Rooms and Restrooms
Penalty
Summary
The facility failed to ensure that call lights were functioning in three residents' rooms, specifically in both the bedrooms and restrooms. Multiple observations revealed that when the call lights were activated in these rooms, the visual indicators above the doors did not illuminate, making it impossible for staff in the hallway to know when assistance was needed. Interviews with residents and staff confirmed that residents experienced significant delays in receiving help, with one resident reporting waiting over an hour after activating the call light. Staff, including CNAs and the Assistant Director of Nursing, were observed not checking restrooms when call lights were activated, even when the restroom doors were closed, and the malfunctioning lights were not visible in the hallway. Further review showed that the maintenance director did not routinely check the functionality of bathroom call lights, only inspecting them if notified of an issue. The maintenance log used to check room temperature did not include checks for call light functionality, and the maintenance director was unaware of the malfunctioning call lights until informed by staff. The facility's policy required the call system to remain functional at all times, but this was not adhered to, as evidenced by the lack of regular checks and delayed reporting of issues by staff, including agency CNAs.