Failure to Maintain Functioning Call Light System for Residents
Penalty
Summary
The facility failed to ensure that the call light system was functioning for all residents, resulting in 23 out of 77 residents being affected. Nine residents had no functioning call light, while an additional fourteen experienced intermittent functionality. Residents without working call lights were provided with hand bells as an alternative means of summoning assistance. Staff reported increasing the frequency of rounding for these residents, but there was no clear documentation on how often these rounds occurred. Several residents described having to rely on hand bells or even calling the facility by telephone to request help, with some stating that their call lights had been nonfunctional for weeks or even months. Interviews with staff, including LPNs, CNAs, and the Director of Maintenance, confirmed that the call light system on the north end of the building had not been working for approximately two and a half weeks, with some rooms experiencing intermittent issues. The Administrator acknowledged the problem and stated that service providers had been contacted for repair or replacement quotes, but no written documentation of these quotes was available. The maintenance staff indicated that the system was old and had a power issue, and some vendors reportedly refused to provide written estimates due to the age of the system. Policy and job description reviews revealed that while maintenance staff were responsible for keeping equipment in working order and obtaining contractor quotes, the facility's policies lacked specific guidelines for maintaining or repairing the call light system when it was not functioning. The policies only addressed providing hand bells and increasing staff rounds as interim measures, without detailing steps for timely repair or replacement of the system.