Failure to Maintain Functioning Nurse Call System in Resident Bathrooms
Penalty
Summary
The facility failed to provide a functioning nurse call system in resident bathrooms and bathing areas for all residents, as required by facility policy. Observations, interviews, and record reviews revealed that the nurse call system in resident bathrooms had been non-functional for an extended period. Multiple residents reported that the system had been down for months, and staff confirmed ongoing issues with the system despite attempts at repair. In several instances, activating the call system in resident bathrooms did not result in any visual or audible alert at the room door or nurse's station, and this was verified by both nursing and maintenance staff. Four residents with significant medical conditions and varying levels of dependence for toileting were directly affected by the non-functioning call system. These residents included individuals with diagnoses such as hemiplegia, chronic pain, osteoarthritis, diabetes with neuropathy, and a history of falls. Each resident's care plan emphasized the need for prompt response to call lights and the importance of having the call system within reach, especially given their fall risk and dependence on staff for toileting assistance. Despite these documented needs, residents were left without a reliable means to summon help while in the bathroom. Residents described experiencing fear, anxiety, and in some cases, actual harm due to the inability to call for assistance. One resident reported waiting up to 30 minutes for help after being left on the toilet, while another described falling in the bathroom and being unable to reach the provided bell or call for help, resulting in injury and a subsequent emergency room visit. Staff and residents both reported that complaints about the broken system had been made to the facility administrator over several months, but the issue remained unresolved at the time of the survey.