Call Light System Failure Leads to Delayed Resident Assistance
Penalty
Summary
The facility failed to ensure that the call light system was fully operational in all resident areas, including bathrooms and bathing areas. Observations revealed that call lights on all resident halls were activated but not sounding, and the system at the nurse's station was not alerting staff when call lights were activated. Multiple interviews with residents, family members, and staff confirmed that the auditory alarms had not been functioning for approximately five weeks, and that staff were not being notified of call lights at the nurse's station. Residents reported long wait times for assistance, sometimes up to an hour, and family members observed staff taking up to 40 minutes to respond to call lights. Some residents had to leave their rooms and call out in the hallway to get help. The Assistant Director of Nursing and the Assistant Nursing Home Administrator both confirmed the lack of auditory alerts, with the latter stating that she was told the system was considered functional as long as the lights worked. Maintenance staff reported ongoing issues with obtaining replacement parts for the outdated system, with several unsuccessful attempts to repair it using refurbished components. Documentation provided included invoices and delivery records for replacement parts, and the facility's grievance log showed five complaints related to call lights in the previous month.