Failure to Maintain Functional Call System in Resident Bathroom
Penalty
Summary
A deficiency occurred when the facility failed to provide a functional call system in the bathroom of a resident who was at risk for falls and required assistance with toileting and transfers. The resident's care plan specifically included interventions to ensure the call light was within reach and functional, due to diagnoses such as unsteadiness, repeated falls, and generalized muscle weakness. Despite these documented needs, the call light in the resident's bathroom was not working for approximately two weeks. Staff interviews revealed that the LPN was aware of the non-functioning call light and had submitted a work order, but the Environmental Operations Director was unable to repair it and delayed notifying higher-level maintenance and administration. The Director of Nursing and Administrator were not made aware of the issue until the day of the survey, and there was no existing policy on call light systems in the facility. The maintenance job description required regular checks and repairs of nurse call systems, but this was not effectively carried out in this instance. Further investigation showed that the facility's call system was outdated, with no available replacement parts, and the outside technician was only able to partially restore functionality after being notified. The lack of timely communication and follow-through on maintenance responsibilities contributed to the prolonged period during which the resident did not have access to a working call system in the bathroom, despite being dependent on staff for toileting and transfers.