Failure to Maintain Functional Resident Call System in Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to ensure that a functioning resident call system was available in each resident's bathroom and bathing area on the second floor nursing unit, affecting all seven residents reviewed. Observations and interviews revealed that the installed call bell system was not working properly, with some residents resorting to yelling for help or using hand-held silver bells, which could not be heard from a distance. In several cases, the call bells were either missing, out of reach, or non-functional when tested. For example, one resident's call bell was not present in the room, and another's was placed on a dresser out of reach. Testing of the call systems confirmed they were non-functional in multiple rooms and bathrooms. To compensate for the non-working wired call bell system, the facility provided a wireless call bell system for some residents. However, this system only notified staff at the nursing station and did not provide portable notifications to staff elsewhere in the unit. Additionally, no working call light system was observed in the bathrooms for several residents. Maintenance staff confirmed the deficiencies during testing, and the Nursing Home Administrator acknowledged ongoing problems with the call bell system due to its age and lack of available replacement parts.