Failure to Maintain Functional Call Light System Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide a fully functional call light system for residents, as required by policy and state regulations. The call light system did not illuminate outside resident rooms or make an audible sound when activated, and staff were not provided with pagers to receive notifications of call lights. Instead, staff had to physically check a monitor at the nurses' station to determine if any call lights were on, which led to significant delays in response times, especially for staff assigned to areas distant from the nurses' station. The facility's previous exception to use a wireless call system with pagers had expired, and the required pagers were not available or functional for an extended period. Two residents were directly affected by these deficiencies. One resident, with diagnoses including COPD, stroke, diabetes, depression, and anxiety, required assistance with activities of daily living and was frequently incontinent. This resident reported waiting 15 to 30 minutes, and sometimes up to an hour, for staff to respond to call lights at night, resulting in urinating in bed and experiencing skin discomfort and embarrassment. Another resident, with chronic respiratory failure, depression, anxiety, and diabetes, also required substantial assistance and was frequently incontinent. This resident reported waiting up to an hour for staff to respond, resulting in having to lie in feces, which caused feelings of indignity and anger. Staff interviews confirmed the lack of functional pagers and the absence of visual or audible alerts from the call light system. Staff described the need to walk to the nurses' station to check for call lights, with some reporting that pagers had not been available for months and that residents had complained about delayed responses. Observations by surveyors corroborated that the call light system did not function as intended, with no lights or sounds activating when tested in resident rooms.