Failure to Provide Functional Call Devices for Residents
Penalty
Summary
The facility failed to provide functional call devices for two out of three sampled residents, resulting in the absence of a means for these residents to communicate their needs to staff. Both residents had no cognitive impairment and required substantial to maximal assistance with activities of daily living, including toileting, transfers, and mobility. Observations revealed that the call lights in their rooms did not activate when pressed, and no alternative call bells or devices were available at their bedsides. One resident reported that her call light had not worked for two weeks, requiring her to go to the nurse’s station for assistance. A review of the facility’s maintenance log confirmed that the call light issues for these residents began several days prior and had not been resolved. The facility’s policy required that if the call alert system could not be repaired immediately, an alternative process such as tap bells or auxiliary aids should be implemented, but this was not done. Staff interviews acknowledged the lack of functional call lights and the absence of alternative alert systems for the affected residents.