Inaccessible Call Light System in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that a working call system was accessible in each resident's bathroom and bathing area for 11 out of 15 rooms reviewed. Observations revealed that in multiple rooms, the call light cords were wrapped around the metal assistance bars next to the toilets, making them unreachable from the floor and approximately two feet above the ground. When attempts were made to pull the call light cords from the floor, the system did not activate, as the tension was absorbed by the metal bar rather than triggering the call system. Further observations confirmed that the call system functioned only when the cords were pulled without obstruction. During an interview, the DON explained that the cords were wrapped around the bars to prevent residents from slipping on them, acknowledging that this practice could pose a safety risk by making the call system inaccessible in emergencies. The facility's policy required that each resident have a means to call staff for assistance from the bed, toileting/bathing facilities, and from the floor, but the observed practice did not comply with this policy. No incidents of falls with inability to use the call system were reported at the time of the survey.