Non-Functioning Call Light System in Resident Room and Bathroom
Penalty
Summary
The facility failed to ensure that the call light system was functioning properly for two residents residing in the same room. Both residents had moderate cognitive impairment and required assistance due to their medical conditions, including a displaced comminuted fracture of the left patella and surgical aftercare following digestive system surgery. Observations and interviews revealed that the call light in their room did not activate the light above the door or register at the nurse's station, and one resident reported not being given a call bell. Both residents described significant delays in receiving assistance, with one stating she had to call out for help and the other reporting waits of up to two hours. Multiple staff members, including the DON, DSD, and an RN, confirmed through direct observation that the call light system was not working as intended. Attempts to replace the call light cord and activate the system were unsuccessful, and the emergency call light in the bathroom required excessive force to activate. The facility's policy required the call system to remain functional at all times, but this was not maintained, as confirmed by staff interviews and direct testing of the system.