Failure to Ensure Call Light Accessibility During Call System Outage
Penalty
Summary
A deficiency was identified when a resident with a right femur fracture, muscle weakness, and difficulty walking was found without access to a functioning call light system. The resident, who was cognitively intact and required assistance with transfers, was observed sitting on the edge of her bed, unable to reach a bell placed on the opposite side of the bed. She reported having to yell for assistance, with no staff responding until the surveyor intervened. The resident also stated that there was no working call system in her room or bathroom and recounted an incident where she was left on the commode for 30-45 minutes after calling for help. Staff interviews confirmed that the call system had been down for several days, and residents were provided with bells as an alternative means to request assistance. Staff reported that they attempted to ensure residents had their bells with them, including during bathroom visits, and conducted 15-minute checks. However, it was acknowledged that the bells were not always within reach and were less effective than the standard call system, making it more difficult to identify which resident needed help. The administrator confirmed the call system outage and stated that residents were expected to take the bells with them.