Failure to Maintain Operational and Accessible Call Light System
Penalty
Summary
The facility failed to maintain a consistently operational and accessible call light system for multiple residents across several halls, resulting in extended call light response times and unmet resident needs. Observations revealed that call lights were not always within reach of residents, with one resident found with the call light apparatus touching the floor and not accessible, despite care plans specifying that the call light should be attached to the resident's clothing. Family concerns were documented regarding residents being left without call lights and having to call out for help without staff response. Several residents reported that their call lights were not functioning properly, with one resident demonstrating to the surveyor that the call light did not activate consistently, requiring multiple attempts before it worked. This resident also reported having to call the front desk for assistance when the call light failed. Another resident stated that their call light was not working for several days after admission, and only after reporting the issue did they receive a replacement cord. Multiple residents described slow or absent staff responses to call lights, with documented response times frequently exceeding 30 minutes and, in some cases, over an hour. Staff interviews revealed that the call light system relied on pagers and a central computer screen to alert staff to resident needs. However, several staff members did not have pagers on their person, and the central computer screen for several halls was not functioning and had not been operational for months. The maintenance director confirmed the screen had been out of service since their employment began. Without functioning pagers or the central screen, staff would not be aware of active call lights. These failures directly contributed to residents' needs going unmet, including assistance with toileting and other personal care.