Failure to Maintain Working Call Light System for Multiple Residents
Penalty
Summary
The facility failed to ensure that a functioning call light system was available in each resident's bathroom and bathing area for five of seven sampled residents. Instead of repairing or replacing broken call light cords in a timely manner, the facility provided hand bells to residents whose call lights were not working. Observations confirmed that residents were using hand bells, and staff interviews revealed that these bells could not be heard from other rooms or the nurse's station, resulting in delayed or missed responses to residents' requests for assistance. Residents affected by this deficiency included individuals with significant medical needs and mobility limitations, such as heart disease, muscle weakness, unsteadiness, dementia, depression, vertigo, stroke, and difficulty walking. Care plans for these residents specifically required that call lights be kept within reach and that staff respond promptly to requests for assistance. Despite these documented needs, the broken call light cords were not repaired for extended periods, with maintenance logs showing delays in ordering and installing replacement parts. The Director of Maintenance acknowledged that broken call light cords accumulated because of time constraints and delays in receiving ordered parts. Maintenance records indicated that some residents had been using hand bells for several weeks, and staff confirmed that this was a temporary solution due to the lack of available working call light cords. The facility's own policies required timely maintenance of equipment, but these were not followed, resulting in the ongoing use of inadequate communication devices for residents in need.