Failure to Maintain Functional Call Light System During Power Outage
Penalty
Summary
During an 11-hour power outage, the facility failed to ensure that the call light system, which allows residents to signal for assistance, remained functional for four sampled residents. These residents had significant medical conditions, including morbid obesity, history of falls, hemiplegia, hemiparesis, osteoarthritis, epilepsy, cerebral palsy, hypertension, acute respiratory failure, end stage renal disease, and cerebral infarction. All four residents were assessed as high risk for falls and required varying levels of assistance with activities of daily living such as toileting, bathing, and dressing. Their care plans specifically required that call lights be within reach and functional to ensure prompt staff response to requests for help. Interviews with the residents confirmed that the call light system was not operational during the power outage, and none of them received an alternative means to request assistance, such as a temporary bell or device. One resident reported having to yell for help when assistance was needed. Staff interviews corroborated that the call light system was nonfunctional during the outage, and although the facility had some temporary bells, there were not enough for every resident. Maintenance records confirmed the duration of the power outage, and staff acknowledged the lack of sufficient alternative signaling devices. A review of the facility's policies and procedures indicated that each resident should have a means to call staff for assistance at all times, and that the call system must remain functional. The maintenance department is responsible for ensuring that all building systems, including the call light system, are maintained in a safe and operable manner. The failure to provide a functioning call system or adequate alternatives during the power outage was inconsistent with these policies and directly affected residents who were dependent on staff for their care and safety.