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F0919
E

Failure to Ensure Resident Access to Call Lights

Great Falls, Montana Survey Completed on 06-19-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed that multiple residents did not have access to functioning call lights in their rooms or bathrooms, as required by facility policy. One resident was found lying in bed unable to reach the call light, which was hanging off the light fixture above the bed. Another resident did not know where the call light was, as it was placed under equipment on a countertop in the corner of the room, making it inaccessible. A third resident was found attempting to get up from bed without a call light present, and had to call out for help until staff responded. A fourth resident was observed sitting on the side of the bed, anxious and shaking, with no call light in the room and the bed alarm not sounding; staff had to be notified by the surveyor to assist the resident. Interviews with staff revealed that in some units, particularly the memory unit, call lights were not provided, and staff relied on regular rounding every two hours instead. Staff also indicated that some residents did not know how to use the call lights appropriately, further contributing to the lack of access. Facility policy requires that the call system be in working condition at all times and located near the patient's bed and in the restroom, but these requirements were not met for several residents, preventing them from contacting staff for assistance when needed.

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