Failure to Ensure Functioning and Accessible Call Light System
Penalty
Summary
The facility failed to ensure that a functioning call light system was available and accessible for multiple residents. Several residents reported or were observed to have non-functioning call lights in their rooms and bathrooms. One resident stated that upon admission, the call light did not work and it was not fixed until the following day, during which time no alternative means to summon staff was provided. Another resident reported a non-working call light, which was confirmed by staff, and there was no indication that maintenance had been notified in a timely manner. Observations and interviews confirmed that call lights in several rooms were either not functioning or not present, and in one case, a call light was found out of reach in a closed dresser drawer, making it inaccessible to the resident. Staff interviews revealed inconsistent practices regarding the placement and reporting of non-functioning call lights. Some staff stated that call lights should be within reach of residents and that maintenance should be notified through a paper form or work order system if a call light was not working. However, there was no evidence of a formal policy on call light functionality, and maintenance staff indicated that they were not always notified of issues. The maintenance director reported that monthly checks were performed in a limited number of rooms and that pre-admission checklists included call light functionality, but these measures did not prevent the deficiencies observed. Multiple staff members confirmed that call lights should not be placed in drawers or out of reach, and that non-functioning call lights should be reported immediately. Despite these expectations, several rooms were found to have call lights that were either not working or not accessible to residents. The lack of a consistent system for ensuring call light functionality and accessibility contributed to the deficiency, as evidenced by the observations, interviews, and record reviews documented in the report.