Failure to Maintain Audible Call System on Secured Unit
Penalty
Summary
The facility failed to ensure that all residents on the secured unit had access to a functioning call system that would audibly alert staff to their needs. During an environmental tour, it was observed that when the call light was pressed in two residents' rooms, the light outside the room illuminated, but no audible sound was emitted from the call system at the nurse's station. An LPN present at the nurse's station confirmed that the call system's volume had been turned down, preventing staff from hearing when a call light was activated. When the volume was increased, the system produced an audible alert as intended. The LPN verified that if the volume remained low or off, staff would not be audibly notified of any resident call lights on the unit. Further interview with the Director of Plant Maintenance revealed that he had previously noticed the call system units with the sound turned off or set too low to be heard by staff. Review of the facility's policy indicated that residents have the right to a method of communicating their needs to staff. This deficiency had the potential to affect all 13 residents living on the secured unit, as it compromised their ability to reliably alert staff for assistance.