Failure to Maintain Functional Call Light System for Resident Notification
Penalty
Summary
The facility failed to provide residents with an approved and functional call light system in resident bathrooms and bathing areas. Observations revealed that the call light system did not have a process in place to notify staff of sounding call lights when notifications could not be heard in the hallways, and staff were not provided with pagers for notification. Only one functional pager was available, which was kept at the nurses' station, and several pagers were either broken or missing battery covers. The light above the resident's door did not illuminate when the call light was activated, and the pager could not be heard at the end of the hall. Staff interviews confirmed that they relied on checking the computer at the nurses' station to see if a resident had pressed their call light, as the pager system was unreliable and difficult to use. The facility's policy required that call lights directly relay to a staff member or a centralized location to ensure an appropriate response, and that all staff be educated on the proper use of the system. However, staff reported that only one pager had worked for at least a month, and it was not consistently carried by staff. The exception previously granted by the Department of Health and Senior Services was contingent on all direct care staff carrying and using wireless nurse call pagers at all times, a condition that was not met. The facility census was 33, and the lack of a reliable call light notification system meant that staff were not always aware when residents required assistance.