Non-Functioning Call Light System for Resident Requiring Assistance
Penalty
Summary
A deficiency was identified when a resident's call light system was found to be non-functional. During an observation, the call light was seen on the resident's bed, and the resident reported that it was broken. A Licensed Vocational Nurse confirmed that activating the call light did not produce any audible or visible signal above the resident's door, indicating the system was not working. The facility's policy requires that each resident have a functional call light system at all times, both for audible and visual alerts. The affected resident had a history of encephalopathy, cerebral infarction, and lack of coordination, and was assessed as moderately impaired in cognitive skills. The resident required supervision or assistance with bathing and setup or clean-up assistance with toilet hygiene, personal hygiene, and eating. The failure to provide a functioning call light system was confirmed by both nursing staff and a review of facility policy, which mandates that residents must have a means to call for staff assistance from their bed and bathroom areas.
Plan Of Correction
Immediate Plan of Correction a. The call light in room 117B for resident 55 was immediately fixed by the Maintenance Supervisor on 6/9/25. Corrective Action for Others Affected On 6/09/25, the Maintenance Supervisor checked all rooms and did not find any other residents affected by the deficient practice. Measures Taken to Prevent Reoccurrence a. The administrator in-serviced the Maintenance Supervisor on 06/17/25 regarding the importance of regularly checking the call system to be able to promptly assist residents as may be needed. b. On 06/17/25, the DSD in-serviced the direct care staff to report issues with the call system. c. On 06/17/25, the administrator in-serviced the department heads to make sure that they check the call light system for its functionality to be able to promptly assist residents as may be needed. Performance Monitoring Starting 7/01/25, the Maintenance Supervisor will make weekly rounds in 5 rooms, for the next 3 months, to check the functionality of the call systems. The Maintenance Supervisor will report any findings during the monthly QAPI meeting for the next 3 months. Immediate Corrective Action for resident affected by this deficient practice DSD in-serviced CNA 6 on 6/16/2025 on Dementia Management. DSD in-serviced CNA 7 on 6/16/2025 on Dementia Management.