Failure to Maintain Operational Call System in Resident Room
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's call system was operational. The resident, who had diagnoses including dysphagia, end stage renal disease, and congestive heart failure, required assistance with most activities of daily living and had intact cognition. The resident reported that their call light was not answered in a timely manner, sometimes waiting hours or not being answered at all. During observation, the resident activated their call light to request water, but after 45 minutes, no staff had responded, and the indicator light above the doorway was not illuminated. A Certified Nursing Assistant confirmed that the call light button was working, but the indicator light was out, so staff were unaware of the resident's request. The CNA stated that the call light had been broken all weekend and that there was no maintenance staff available on weekends. The Maintenance Director later explained that the batteries in the call light system were depleted and needed replacement, but maintenance was not notified of the issue until the following morning. Facility policy required staff to notify maintenance if a call light was not working, but this procedure was not followed.