Failure to Maintain Accessible and Functional Call Light System
Penalty
Summary
The facility failed to ensure that a working call light system was available and accessible in resident bathrooms and bathing areas, as required by policy. Specifically, two call lights in the 400 hall shower room were found without cords, rendering them nonfunctional. Staff, including CNAs and a nurse, acknowledged that they did not report the broken call lights, despite knowing the importance of doing so. The Unit Manager and Interim Director of Nursing confirmed that staff were expected to report such issues through the TELS maintenance system, to which all staff had access and training. The Maintenance Director stated that he performed monthly checks and had recently inspected the area, but could not provide documentation of repairs for the missing cords. Additionally, a resident with significant mobility impairments and dependence on staff for toileting and dressing was observed on two occasions with their call light on the floor and out of reach. The resident was unable to access the call light to request assistance and expressed a need for help. Staff confirmed the call light was not within reach and were unaware of how long it had been inaccessible. The Unit Manager reiterated that call lights should always be accessible to residents, but this standard was not met in this instance.