Call Light System Malfunction Due to Improper Resetting of Bathroom Switch
Penalty
Summary
The facility failed to ensure that the resident call light system remained functional for all residents on the second floor on 5/3/2025 and 5/4/2025. The deficiency occurred when a bathroom call light switch in one of the resident rooms was not properly reset by staff after being triggered. Instead of returning the switch fully to the 'up' position, it was left halfway, which caused the entire call light system on the second floor to malfunction and enter safety mode. As a result, all call lights for the second floor were activated on the nurse’s station panel, and residents were unable to use the call system to request assistance during this period. During this time, 71 residents on the second floor were affected, including a resident with a history of autonomic nervous system disorder, falls, contractures, muscle weakness, mild cognitive impairment, and a history of TIA. This resident was dependent on staff for all activities of daily living and reported that the call light system was not working throughout the night, requiring the use of a hand bell to summon staff. The resident emphasized the importance of the call light system for requesting help with personal care and in situations of feeling unwell. Interviews with facility staff, including the Maintenance Director and DON, confirmed that the malfunction was due to improper resetting of the bathroom call light switch. The facility’s policy required that each resident have a functional means to call staff from their bed and bathroom at all times, but this was not maintained due to the failure to properly reset the switch, resulting in a system-wide outage for the second floor.