Failure to Provide Accessible Call System During Outage
Penalty
Summary
The facility failed to provide an alert call system for 20 out of 44 residents after the electronic call system on Station 3 North stopped working. This deficiency was identified during an unannounced visit following a complaint about non-functioning call lights. Observations revealed that multiple residents, including those with significant cognitive and physical impairments, did not have access to either the electronic call system or manual call bells at their bedsides. In several cases, manual call bells were not present or were placed out of reach, preventing residents from being able to summon staff for assistance. Interviews with facility staff, including the DON, Administrator, and Director of Maintenance, confirmed that the electronic call light system had been out of service for several days. While efforts were made to procure and distribute manual call bells, documentation and staff interviews indicated that not all residents received them, and some bells that were distributed were subsequently missing or inaccessible. The Director of Staff Development stated that staff were instructed to check on residents every 30 minutes, but there was no documentation of these checks, and staff were unaware of the whereabouts of missing call bells. Residents affected by the deficiency included individuals with a range of medical conditions such as stroke, Parkinson's disease, COPD, dementia, and sepsis. Many of these residents had impaired cognition, limited mobility, or were dependent on staff for daily activities. Some had a history of falls within the facility. The lack of a functioning call system or accessible manual call bells left these residents without a reliable means to request assistance, as observed during the surveyor's room rounds.