Failure to Maintain Fully Functional Call Light System
Penalty
Summary
The facility failed to ensure that the call light system was fully functional and properly maintained for one resident. When the resident pressed the call light button, the call light above the room door activated, but the corridor call lights located on the wall and above the double door did not illuminate. This incomplete functionality was confirmed through observations, interviews with staff, and review of records. The resident, who was cognitively intact and capable of making health decisions, expressed ongoing concerns about delayed staff response to call lights. Staff interviews confirmed that the corridor call lights did not illuminate when the resident activated the call light, making it difficult for staff to know when assistance was needed unless they were physically near the room. Further investigation revealed that the call light system had not been reprogrammed after servicing, and the issue had not been reported to maintenance or facility leadership. The maintenance request log and call light maintenance log were not provided for review. Staff, including CNAs and the Assistant Maintenance Supervisor, acknowledged the importance of the corridor call lights for timely response and resident safety. The facility's policy required immediate notification and repair of malfunctioning call lights, but the Director of Nursing and other leadership were unaware of the issue until it was brought to their attention during the survey.