Non-Functional Call Light System in Resident Room
Penalty
Summary
A deficiency was identified when a resident's call light system was found to be intermittently non-functional. The resident, who had diagnoses including bilateral primary osteoarthritis of the hip, asthma, and a urinary tract infection, required moderate to maximal assistance with activities of daily living. During multiple observations, the resident pressed the call light, but the light outside the room did not activate, indicating the system was not consistently alerting staff. The resident reported that staff sometimes did not answer the call light, or responses were delayed, particularly when assistance was needed for toileting and changing incontinence briefs. Further investigation by the Maintenance Director revealed that the call button was not reliably working, with a visible crack in the red button and possible wiring issues. The Director of Nursing confirmed that if call lights are not functioning, staff may not be aware when residents need help. Review of facility policies indicated that call lights are required to be plugged in and functional at all times, and that maintenance is responsible for ensuring the system is in good working order. The deficiency was based on direct observation, resident interview, and review of facility records and policies.