Failure to Ensure Timely Resident Care Due to Prolonged Call Light System Outage
Penalty
Summary
The facility failed to meet the timely care needs of six residents due to a prolonged outage of the call light system across multiple units. Residents reported that the call system had been nonfunctional for several weeks to months, and they were instead provided with small hand bells to request assistance. Several residents expressed that the hand bells were difficult to use, especially for those with physical limitations such as numbness in the hands or the need for bilateral wrist and hand splints. In some cases, residents were unable to locate their hand bells or could not bring them into the bathroom, leaving them unable to call for help when needed. Observations and interviews revealed that staff were often unable to hear or identify which resident was ringing a hand bell, leading to significant delays in response times. One resident reported waiting an hour and a half for assistance to use the restroom, while another was observed ringing their bell multiple times without staff response. Staff confirmed the difficulty in distinguishing the source of the bell sounds and noted that they had to physically check each room to determine who needed help. There was also a lack of specific training or program changes implemented to address the outage, and staff were not provided with formal guidance on how to monitor or assist residents during this period. Facility documentation showed ongoing issues with the call light system, including multiple units being affected and no clear timeline for repair. Review of policies indicated that the facility was required to provide accessible call lights and respond in a timely manner, but these standards were not met during the outage. Quality Assurance meeting agendas and education records did not reflect a formal action plan or targeted education regarding the outage, and invoices confirmed ongoing repair attempts without resolution.