Failure to Maintain Resident Call System in Bathrooms and Bathing Areas
Penalty
Summary
The facility failed to effectively maintain the resident call system, impacting 61 residents. Observations showed that while the call system was functioning in several resident rooms on the South Unit, an interview with a resident indicated dissatisfaction with the current call system, expressing a preference for the previous system. The facility's policy requires that each resident's bedside, toilet, and bathing area be equipped with a call light, and that staff and residents be educated on its use. The policy also mandates immediate reporting and alternative solutions if the call system is not functioning. Despite these requirements, a review of the facility's maintenance work order system and the Direct Supply TELS Work Orders for the past 60 days revealed no specific entries related to the resident call system. This lack of documentation suggests that issues with the call system may not have been reported or addressed as required by facility policy, increasing the likelihood of delayed emergency response or negative outcomes for residents.
Plan Of Correction
F919 - Resident Call System Element #1: The Maintenance Department repaired the cited inoperable call bell systems and ensured that the documented resident call lights were functioning properly. Element #2: The Maintenance Director and/or designee will conduct a 100% audit of call systems to ensure each resident has a call light that is appropriate for their current status and properly functioning. Element #3: The Administrator reviewed the policy on Call Lights and revised as necessary. Community staff were re-educated on the policy to include reporting of inoperable equipment. Element #4: The Maintenance Director and/or designee will perform a weekly facility-wide call system inspection for 12 weeks and log all maintenance responses. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025