Inadequate Audible Call Light System in Station 2
Penalty
Summary
The facility failed to ensure that the call light system in Station 2 had an adequate audible sound, which could prevent residents from receiving timely assistance from staff. Resident Council meeting minutes from March and April 2025 documented ongoing concerns about delayed call light responses, particularly during the evening shift in Station 2. During a meeting, a resident reported having to get out of bed and call out for help due to unaddressed call lights. Direct observation confirmed that the call light panel in Station 2 was illuminated for a resident's room, but no audible sound was heard, even with two LVNs present at the nurse's station. Interviews with staff revealed that the call light system in Station 2 produced only a faint sound, which was not sufficient in the noisy environment of the nurse's station and was not audible outside the station. The maintenance staff confirmed that the sound from the call light panel in Station 2 was much fainter compared to other stations. The Maintenance Director stated he was unaware of any issues with the call light's audibility and had only checked for visual functionality. The Administrator was aware of concerns about response times but not about the call light system's sound issue. The facility's preventative maintenance policy required equipment to be maintained in a safe and operable manner, but the lack of attention to the audible function of the call light system led to this deficiency.