Failure to Maintain Functioning Call System in Resident Areas
Penalty
Summary
The facility failed to provide a properly functioning call system in resident bathrooms and bathing areas for two residents. One resident, with diagnoses including traumatic brain injury, heart disease, renal insufficiency, neurogenic bladder, and reduced mobility, required substantial assistance for transfers and was instructed to use the call light for help. This resident reported waiting up to forty-five minutes for staff assistance, attributing the delay to the malfunctioning call system, which was not visible or audible at the nurse's station. Another resident, with diabetes, depression, vision deficits, and heart disease, used a walker and required prompt staff response. This resident confirmed awareness of the call system malfunction and described having to search for staff when assistance was needed, as the call light in their room was not detected at the nurse's station unless staff happened to walk by and see the overhead light. Staff interviews confirmed the call system was old, frequently malfunctioned, and did not consistently activate sound or light at the nurse's station for several halls. Staff reported that only one hall had a functioning sound system, while others relied solely on overhead lights, which could be missed if not directly observed. The administrator acknowledged ongoing issues with the system, frequent repairs, and the need for replacement. Facility policy required each resident room to have a functioning call light system, but observations and interviews demonstrated that this standard was not met for the affected residents.