Failure to Ensure Accessible and Functional Call Light System
Penalty
Summary
The facility failed to ensure that call lights were consistently available, accessible, and functional for multiple residents, resulting in unmet needs and safety concerns. Observations revealed that one resident, identified as a fall risk, was unable to locate his call light, which was draped over a fall mat and lacked a clip for proper placement. Staff were uncertain about the correct placement of call lights for residents with dementia. In the shower room, a wheelchair-bound resident was left unattended for an extended period without access to a reachable call light, as the pull cord was missing and the call light station was obstructed by shower chairs. Staff confirmed that residents should not be left alone in the shower room, and the lack of accessible call lights posed a safety risk. Interviews with several residents indicated prolonged wait times for call light responses, with some reporting waits of up to four hours or having to repeatedly request assistance. Residents described situations where call lights were not working, had to be pulled from the wall, or were not reachable due to their physical limitations. Staff interviews and facility work order records showed that multiple call lights required repairs within a single month, and some staff expressed concern about the frequency of these issues. Facility grievance records further documented complaints about non-functional call lights and delayed responses, with some residents' needs not being met even after staff responded to the call light.