Failure to Maintain Functional Call Light System for Resident Assistance
Penalty
Summary
The facility failed to maintain a functioning resident call light system, resulting in staff not being directly alerted to residents' requests for assistance. Observations showed that when a resident pressed the call light in their room, the only indication was a light above the door, with no audible or visual alert at the nurses' station or a centralized staff area. Multiple staff members, including licensed nurses, confirmed that the call light system had not been working properly for at least a year, and that staff were expected to visually check for call lights while walking the halls. During several observations, staff walked past rooms with active call lights without responding, and there were periods when no staff were present in the hallways or at the nurses' station to notice the call lights. The administrator and DON acknowledged the lack of a functioning call light board or alarm and confirmed awareness of the issue for several months. Facility policy required that residents have a means of communication with nursing staff and that call lights be answered within 3-5 minutes. However, observations documented call lights remaining unanswered for extended periods, including one instance where a call light was left on for approximately 18 minutes before being answered. Staff interviews confirmed that the lack of an audible or visual alert at the nurses' station made it difficult to respond promptly to residents' needs, and that the system had not been repaired despite being reported as nonfunctional.