Failure to Provide Working Call Systems for Two Residents
Penalty
Summary
The facility failed to ensure that two residents had access to a working communication system to call for assistance, as required for reasonable accommodation of resident needs. One resident, who had a history of nontraumatic intracerebral hemorrhage, acute respiratory failure with hypoxia, expressive dysphasia, and hemiplegia, did not have a call light or bell in her room from the time of admission. Observations and interviews confirmed that the resident's room lacked a call light for over a week, and neither the care plan nor staff actions addressed this absence. The Director of Nursing (DON) and other staff were unaware of the missing call light until the day of the survey, and there was no policy or procedure in place for call lights or maintenance requests. Maintenance staff had not received a request for a call light until the survey date, despite staff stating that a request had been made earlier. A second resident, with diagnoses including cerebral infarction, diabetes, arthritis, and dementia, was also found without a functioning call light. The call light cord was observed unplugged and broken, and the resident was unable to use it to request assistance. Staff were unaware of how long the call light had been nonfunctional, and the resident's care plan specifically required the call light to be within reach and for staff to respond promptly to requests for assistance. Interviews with staff and the DON revealed a lack of awareness regarding the status of the call lights and the absence of a systematic process to ensure their functionality. These deficiencies were identified through direct observation, interviews with staff, residents, and family members, and review of care plans and facility policies. The lack of a working call system in both cases was not addressed in the residents' care plans, and staff did not consistently monitor or ensure the availability of alternative communication methods when the call lights were not functional.