Failure to Provide Functional Call System for Residents
Penalty
Summary
The facility failed to provide a functional call system for 32 residents living on the 300, 400, and 500 halls. Multiple residents reported that the call light system had been nonfunctional since their admission, and instead, they were given alternative devices such as bike horns, bells, and whistles to alert staff when assistance was needed. Residents described significant difficulties with these alternatives, including uncertainty about whether staff could hear them, long response times, and the need to repeatedly use the devices to get attention. Some residents did not have any alternative device within reach, and others expressed frustration with the ineffectiveness of the provided solutions. Several residents were cognitively intact, as indicated by their BIMS scores, and were able to clearly articulate the challenges they faced due to the lack of a working call system. Staff interviews confirmed that the call light system on these halls had been out of service since the end of August. Staff acknowledged the challenges in identifying which resident was signaling for help, especially when multiple residents used similar devices simultaneously or when residents' doors were closed. Staff also reported that it was difficult to determine the location of the sound, leading to delays as they walked the halls to identify who needed assistance. Observations further revealed that some residents did not have their alternative devices within reach, and staff had to search for these devices in residents' rooms. Facility leadership confirmed that the call light system had failed and that alternative devices were distributed to residents. However, they also acknowledged that staff had difficulty hearing the devices, particularly for residents at the end of the halls or with closed doors. There was mention of implementing 15-minute checks on affected residents, but there was no documentation to support that these checks were consistently performed. The facility's own policy required a functioning call light system to respond to residents' requests and needs, which was not met during the period in question.