Nonfunctional Call System in Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to ensure that the call system was functional and accessible for two of eight sampled residents. For one resident, the call light device was observed hanging on the wall, out of reach, and when tested, neither the light inside the room nor the indicator outside the door activated, and there was no audible alert. Nursing staff were observed walking in the hallway without responding to the call light, and a CNA confirmed that the device was not working and not within the resident's reach. The resident's care plans specifically required the call light to be within reach and encouraged its use for assistance, and the resident was assessed as having impaired cognition, limited mobility, and a moderate risk for falls. Another resident's call light was also found to be nonfunctional during multiple observations, with the indicator outside the room not lighting up when pressed. A CNA confirmed that the call light did not activate the indicator on the switchboard at the nurses' station, and acknowledged that the resident's needs could go unmet due to the malfunction. This resident had severe cognitive impairment, required assistance with activities of daily living, and was at risk for falls, with care plans instructing staff to keep the call light within easy reach and encourage its use. Interviews with the DON confirmed that staff are expected to check call lights for proper function and accessibility at every shift change, and that a nonfunctioning call light could delay care and services, especially in emergencies. The facility's policy required that the call system remain functional at all times, be routinely maintained and tested, and that calls for assistance be answered promptly.