Failure to Maintain Functional Call Light Systems in Resident Rooms and Bathrooms
Penalty
Summary
Surveyors observed that several resident rooms in the behavioral unit were not equipped with a working call system to summon staff assistance. In one room, the call light was found on the floor behind the bed and out of the resident's reach during multiple observations. Another room lacked a call light entirely for resident use. Additionally, in a bathroom, the call light string was positioned too high on the wall, making it inaccessible to a resident who might fall and be on the floor. Further checks revealed that pulling the call light string or pressing the call button in some rooms did not activate the hallway indicator light, confirming that the call lights were not functioning. Staff interviews corroborated these findings. A CNA confirmed that the call lights in two rooms were not working and acknowledged that this would leave residents unable to alert staff for assistance. An LPN described the staffing levels and the reliance on call lights for residents who could verbalize their needs, while nonverbal residents were checked every 15 minutes. Facility documentation and policy review indicated a commitment to resident safety and accident prevention, but the observed deficiencies in the call system contradicted these stated practices.