Failure to Maintain Functional Call Light System Across Multiple Nursing Stations
Penalty
Summary
The facility failed to maintain a functional call light system for three nursing stations over a period of seven days. According to maintenance records and staff interviews, the call light system at Stations 1, 2, and 3 became non-operational and remained so despite multiple unsuccessful troubleshooting attempts by the Maintenance Director and external technicians. Observations confirmed that the call light system was not working in all three stations during this period. The maintenance logbook did not show evidence of required testing of the nurse call system during the outage. The transformer for the system was found to be damaged and disconnected, and only partial repairs were made by the end of the period, with several rooms still lacking a functional call light system. Staff interviews, including those with the Maintenance Director, Environmental Health Consultant, Administrator, Director of Staff Development, Registered Nurse Supervisors, and the Director of Nursing, confirmed that the call light system was not operational and emphasized the importance of the system for resident safety and timely care. The facility's policy required immediate reporting and replacement of defective call lights, as well as hourly safety checks and documentation until the system was restored. However, the policy was not followed, as the system remained non-functional for an extended period and the required documentation and immediate repairs were not completed.