Non-Functioning Call Light System in Memory Care Unit Bathrooms
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that the call light system was functional in the bathrooms and bathing areas of fourteen residents in the memory care unit. During observations, it was found that when the call light switches inside these restrooms were activated, there were no lights outside the residents' rooms to signal that the call lights had been triggered. This issue was confirmed by staff, including an RN, who checked multiple restrooms and found that the call lights were not working. The staff interviewed were not aware of the malfunction prior to the survey and acknowledged the importance of having operational call lights for resident safety and communication. The residents affected had significant medical and cognitive impairments, including severe or moderate cognitive deficits, risk for falls, incontinence, and mobility limitations. Their care plans specifically included interventions to ensure that call lights were within reach and that staff would assist with toileting and other activities of daily living. Despite these documented needs, the non-functioning call light system meant that residents did not have a means to call for assistance while in the restroom, as required by their care plans and the facility's own policies. Interviews with facility staff, including the DON, ADON, and maintenance manager, revealed a lack of awareness and oversight regarding the functionality of the call light system in the memory care unit. The maintenance manager stated he was new and had not personally checked the call lights in that area, assuming they were working because other units' call lights were operational. The facility's policy required routine monitoring of call lights to ensure they were functional, but this was not carried out in the memory care unit, leading to the deficiency.