Failure to Maintain Functioning Call Bell System in Resident Areas
Penalty
Summary
The facility failed to ensure that a functioning call bell system was available in each resident's bathroom and bathing area on Unit 2 East. On multiple occasions, including during the survey, the audible portion of the call bell system was not working, meaning that when the call bell was activated, only a light illuminated outside the resident's room, but no sound was heard on the unit floor or at the centralized nurse station. Staff interviews confirmed that the sound component of the system was intermittently nonfunctional, requiring staff to visually monitor for illuminated call lights rather than being alerted by sound. Maintenance staff confirmed that the speakers at the nurse's station were not working and that the system sometimes required a computer reset to function properly. The call bell system on Unit 2 East had been upgraded to a different system than the rest of the facility several months prior, but issues persisted both before and after the upgrade. A review of maintenance records showed repeated issues with the call bell system on Unit 2 East over several months, with multiple work orders documenting malfunctions on specific dates. Despite the high priority assigned to call bell repairs, the problem recurred, and some nursing leadership were unaware of the ongoing sound issues. The expectation from some staff was to look for call bell lights and respond as soon as possible, but the lack of an audible alert compromised the intended function of the call system.