Nonfunctional Call Systems in Resident Rooms
Penalty
Summary
The facility failed to ensure that resident call systems were functioning properly in the rooms of two residents who required assistance with activities of daily living. Both residents had significant cognitive and physical impairments, including dementia, schizoaffective disorder, and a history of falls, and were care planned to have call lights within reach to request help. Observations revealed that the call lights in their rooms were not working, and both residents expressed an inability to summon staff when needed. A CNA confirmed that the call lights for both residents were nonfunctional, and the unit manager verified that neither resident had a working call light or an alternative signaling device, such as a bell, in their room. Review of facility policy indicated that staff are required to ensure call lights are plugged in and within easy reach, and to promptly report any defective call lights to the nurse supervisor. Despite these policies, the deficiency was identified through direct observation, resident and staff interviews, and review of medical records and care plans, which all indicated that the required call systems were not available or operational for the affected residents.