Failure to Provide Adequate Resident Call System During Call Light Outage
Penalty
Summary
The facility failed to provide an appropriate and adequate method for residents to call for staff assistance while the call light system was being repaired. For approximately two weeks, the call light system by residents' beds was not functioning, and residents were instead given whistles or bells to use to summon staff. Several residents reported that the whistles were not always within reach, and that staff did not always respond when the whistles were used. In some cases, residents had to walk to the bathroom to use the functioning call light there, despite having mobility limitations and being at risk for falls. Multiple residents with significant medical conditions, including congestive heart failure, COPD, diabetes, chronic kidney disease, Parkinson's disease, and other mobility and cognitive impairments, experienced distress due to the lack of a reliable call system. One resident with respiratory issues became short of breath after blowing the whistle for several minutes without staff response and had to walk to the bathroom to use the call light, which caused further shortness of breath and fear of falling. Other residents expressed anxiety and fear that if they fell or became ill, they would not be able to summon help, especially if the whistle was out of reach or if they were physically unable to use it. Staff interviews revealed inconsistent practices regarding increased rounding and monitoring of residents during the call light system outage. While some staff reported being instructed to increase rounding, others stated they had not received such instructions or were not given specific timeframes for rounds. The facility did not provide a policy regarding the call light system, and the administrator was unaware of any resident complaints or reports of anxiety related to the deficiency.