Failure to Provide Accessible Call System During Outage
Summary
The facility failed to ensure that a working call system was available and accessible to all residents, particularly in bathrooms and bathing areas, after the electronic call system became inoperable. This failure was observed through multiple interviews, record reviews, and direct observations, revealing that several residents, including those with significant medical needs, were left without a functioning call light or an alternative means to summon assistance. One resident, who was admitted with diagnoses including Atrial Fibrillation, repeated falls, heart failure, and morbid obesity, was placed in a bed without a working call system and was not provided with a bell or any alternative device to call for help. The resident experienced chest pain and shortness of breath for over two hours without staff response, ultimately requiring emergency services for a new onset of atrial fibrillation. Other residents were also found to be without working call lights or bells, and staff interviews confirmed that some residents had never been provided with a bell. Residents reported having to rely on roommates or yelling for help, and in some cases, staff were unaware of the inoperability of the call lights. Documentation showed that the facility's call light system had been out of service for an extended period, and there was no documented plan to ensure all residents had access to an alternative call system. The facility's own policy required that all residents have access to a call system at all times, and that defects be promptly reported and addressed, but these procedures were not followed. The lack of a functioning call system affected all 40 residents in the facility, with specific incidents of delayed care and unaddressed needs, including a resident who was left in soiled clothing for hours and another who was unable to call for help during a medical emergency. Staff interviews revealed confusion and lack of communication regarding the status of the call system and the provision of alternative devices. Maintenance records did not reflect timely reporting or repair of the call system failures, and care plans were not updated to reflect the need for increased supervision or alternative call systems during the outage.
Removal Plan
- All resident care plans were updated to ensure residents receive frequent rounding to ensure needs are met and bells are within reach if a call light is found to be inoperable. Staff will complete a work order and submit to the Maintenance Department for service or repairs. The Maintenance Director will keep all work orders which will document what type of repair was conducted. The Administrator and/or Director of Nursing will be responsible for overseeing and maintaining plan until call light system is back online and operating appropriately.
- All staff were in-serviced on the facility's Call Light policy including reporting call bell system defects promptly to the Maintenance Department for servicing and checking rooms frequently until the call light system is repaired, providing dependent residents with a hand bell whenever a call light is found to be inoperable, and answering call lights promptly.
- V2 was educated on the facility's Comprehensive Care Plan policy, including developing a comprehensive care plan after completion of the comprehensive assessment that includes services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, resident's goals for admission and desired outcomes, resident's preference and potential for future discharge, including the resident's desire to return to the community and any referrals to local contact agencies.
- V6 (Maintenance Director) was educated to document when call lights were out of service, when repairs were made, and to keep a service repair/work order binder to document when call lights are out of service and when repairs are made.
- All resident bathrooms were provided with hand bells.
- Daily audits were completed to ensure all call lights were operational and hand bells were within reach of all residents that did not have working call lights with the exception of 300 hall which closed and does not currently have residents. These audits will continue.
- All staff were re-in serviced on ensuring V17 receives a work order whenever call lights are not working and ensuring V17 documents in the maintenance binder when the call lights are inoperable and are repaired.
- The new call system was fully operational and working on all of 100 and 200 hallway bathrooms and resident rooms. All resident rooms and bathrooms had bells as back up call devices. These bells were within reach of all residents.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Call Light Not Within Resident’s Reach: A resident with Parkinson’s disease, dementia, unsteadiness, and a fall history did not have an accessible call light while seated in his wheelchair watching TV. The call light was taped to a positioning pole near the bed, and both the resident and staff confirmed he could only use it if he moved his wheelchair back to the bed.
A resident with functional quadriplegia and stiff, curled fingers did not have an adaptive call light pad in the new room after readmission and was observed using a standard call light button with difficulty. Records showed the resident had previously used a call light pad, but the room was equipped with a standard button instead of the easier-to-use device noted in the resident’s history and care documentation.
A resident dependent on staff assistance with ADLs had a nonfunctioning call device after the cord was found wrapped on the siderail. When the resident activated it, neither the wall box nor the overhead indicator light illuminated, and the ADON and Maintenance Director both confirmed the device was not working. The resident had COPD, morbid obesity, HTN, and moderately impaired cognition, and the care plan directed staff to keep the call light within reach for toileting and incontinence assistance.
Unanswered and Malfunctioning Call Light System: A facility failed to maintain a fully functional call light system when pagers, the nursing station notification terminal, and the reset function did not reliably alert staff. Several cognitively intact residents who needed extensive assistance reported long waits for help, repeated unanswered call light activations, and in some cases bladder and bowel accidents. Staff interviews confirmed that pagers sometimes did not work, the app at the nurses’ station was unreliable, and the system could reset after multiple alerts without staff response.
Nonworking Bedside Call Light: A resident with Parkinson’s disease, dementia, weakness, and impaired coordination had a bedside call light that did not work when she pressed it while in bed, and the hall indicator did not light up. A CNA confirmed the failure, while the Maintenance Supervisor and DON were unaware the call light was not working. An email from the ADM noted there was no policy for call lights.
Call Light Not Kept Within Reach: A resident with chronic respiratory failure with hypoxia and paroxysmal atrial fibrillation, who was cognitively intact and needed partial/moderate assist with transfers, was found unable to reach the call light. The resident believed it was near the bed, but staff located it behind the head of the bed near the wall and placed it beside the resident. The facility policy required a call light or bell access to be kept within reach.
Call Light Not Within Resident’s Reach
Penalty
Summary
A resident with Parkinson’s disease, dementia, unsteadiness on his feet, and a history of falls did not have an accessible in-room call light while seated in his wheelchair. During observation, his call light was wrapped and secured with medical tape to the top of a positioning pole near the head of his bed, with the cord tucked behind the bedside table against the wall. The resident stated he had no access to the call light when he sat in his wheelchair watching television and would have to turn his wheelchair around and move it toward the bed to activate it for staff assistance. A later observation again showed the resident seated in his wheelchair watching television with no access to the call light taped to the positioning pole near his bed. The EMR showed care plan interventions directing staff to encourage him to use his call light and to keep it within his reach. A CNA acknowledged that securing the call light to the pole prevented access when he was in his wheelchair, and the DON agreed the resident could only reach it if he was in bed or able to move his wheelchair to the bed.
Call Light Pad Not Available for Resident With Limited Hand Function
Penalty
Summary
The facility failed to ensure that one of eleven residents, Resident 12, had a call light pad available for use in the resident’s room. Resident 12 had diagnoses including functional quadriplegia and stated that, before the most recent hospitalization, he used a call light pad that was easier to use because his fingers were stiff and difficult to straighten. During observation, Resident 12 was seen holding the standard call light button in his left hand and using the knuckle of his right index finger to depress the button to call for assistance. Record review showed that Resident 12 was initially admitted to the facility and later readmitted after hospitalization and transferred to a different room. The new room was equipped with a standard call light button instead of the adaptive call light pad previously used. A progress note documented that a calling pad was within reach, and later observation showed maintenance staff disconnecting the regular call light button and connecting a call light pad to the wall on the right side of Resident 12’s bed. The facility policy stated that if a resident has a disability that prevents use of the call system, an alternative communication usable for the resident is to be provided and documented in the care plan.
Nonfunctioning Call Device Not Available to Resident
Penalty
Summary
The facility failed to ensure that a resident dependent on staff assistance with ADLs had a functioning call device. During observation on 06/26/2026 at 10:39 a.m., R4’s call device cord was wrapped on the right-side rail. When R4 activated the device, no light illuminated on the call device box attached to the wall or on the overhead indicator box outside the room. R4 stated she had been calling but nobody seemed to notice. At 10:47 a.m., the ADON pushed R4’s call device and there was still no light on the call device box or the overhead indicator outside the room. At 11:00 a.m., the Maintenance Director tested the device and no light was lit on the call device box. He unwound the cord from the side rail and stated it should not have been tied there because raising the head of the bed pulled the cord off the call device box. He stated the cord should have been clipped to the resident’s gown or sheet and replaced the device with a new one. R4’s record showed diagnoses including COPD, morbid obesity, and HTN, with a BIMS score of 11 indicating moderately impaired mental status. Her care plan directed staff to keep the call light within reach and assist with toileting and incontinence care as needed.
Unanswered and Malfunctioning Call Light System
Penalty
Summary
The facility failed to provide a complete and fully functional call light system for residents in their rooms, bathrooms, and bathing areas. The report states that the facility did not have a process in place to notify staff when call light pagers were not functioning, when the nursing station notification terminal was not receiving notifications, and when the system reset a call light without staff answering it. The facility policy required call lights to relay directly to staff or a centralized location, staff education on the system, immediate reporting of problems, and response by all staff who see or hear an activated call light. Resident #16 was cognitively intact, had chronic kidney disease, protein calorie malnutrition, and major depressive disorder, and required assistance with all ADLs including dressing, transferring, and bathing due to lower body weakness. The resident reported being angry and frustrated because a call light pressed at 6:00 A.M. was not answered until after 9:30 A.M., and the resident was still waiting for help with breakfast. The call light log showed repeated activations over multiple dates that alerted staff seven times and were not answered. Staff interviews showed the LPN was not aware the call light was not working, the Social Worker believed the call light was not functioning properly, and the call light would alert seven times and then reset, requiring it to be pressed again. Resident #107 was cognitively intact, dependent for transfers, and required maximal assistance with toileting and showering. The resident’s call light log showed multiple activations that announced seven times over periods of about 45 minutes each without staff response. The resident stated call lights rarely got answered, often took over an hour, and had taken as long as four hours, causing the resident to urinate and defecate on him/herself. The resident also said staff told him/her that sometimes their pagers did not work properly. Resident #115 was cognitively intact, dependent for transfers, and required maximal assistance with toileting and showering. The resident filed a grievance stating no one answered the call light, and the call light log showed repeated activations that announced seven times and were not answered. The resident said staff do not like to answer call lights and that a bell placed on the table was rarely used because staff could not hear it when the door was closed. Resident #62 was cognitively intact, required assistance with most ADLs, and was always incontinent of bladder and bowel. The resident’s call light log showed multiple unanswered activations, and the resident filed grievances about waiting too long for call lights to be answered. The resident reported waiting an hour on average and as long as two to three hours, causing bladder and bowel accidents. Interviews with CNAs, LPNs, RNs, the SSD, Maintenance Director, ADON, DNA staff, DON, and Administrator showed inconsistent understanding of the system, reports that pagers sometimes did not work, that the system sometimes reset after seven alerts, that the nursing station app sometimes displayed “test system not found,” and that staff often relied on residents to report when call lights were not working.
Nonworking Bedside Call Light
Penalty
Summary
The facility failed to ensure that a working call system was available at a resident’s bedside. Resident #51 was admitted with diagnoses including Parkinson’s disease, muscle weakness, lack of coordination, dementia, and anxiety. Her quarterly MDS showed she was usually able to make herself understood, usually understood others, and had a BIMs score of 9/15, indicating moderate cognitive impairment. Her care plan identified an ADL self-care performance deficit related to dementia and Parkinson’s disease, noted impaired visual function requiring eyeglasses, and included interventions to keep the call light within reach and encourage its use for assistance. During an observation, Resident #51 pushed the call light while lying in bed and it did not work, and the hall light did not illuminate. The resident stated that sometimes staff did not come when she pushed the call light. A CNA confirmed the call light was not working. The Maintenance Supervisor stated he was not aware the resident’s call light was not working, and the DON stated she was not aware the call light did not work. The DON stated that because the call light did not work, it could cause a decrease in care and staff not being aware residents needed assistance. An email from the ADM also indicated there was no policy for call lights.
Call Light Not Kept Within Resident Reach
Penalty
Summary
The facility failed to ensure that a working call system was kept within Resident #2's reach. Resident #2 was admitted with diagnoses including chronic respiratory failure with hypoxia and paroxysmal atrial fibrillation, and the quarterly MDS assessed the resident as cognitively intact with a BIMS score of 13 and needing partial or moderate assistance with sit-to-stand transfers. During interview, the resident stated the call light was believed to be on the floor next to the bed, but when the resident reached over the side of the bed, the call light could not be found and the resident said he did not know where it was. At observation, Housekeeper #212 entered the room and found the call light behind the head of the bed near the wall, then placed it next to the resident. The housekeeper stated they had deep cleaned the room earlier that morning and thought they remembered seeing the call light on the floor while cleaning, and could estimate how long it may have been out of the resident's reach. The facility policy titled Resident Rights stated residents should have a method to communicate needs to staff, such as a call light or bell access, kept within reach.
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