Failure to Maintain Functional Call Light System in Resident Rooms
Penalty
Summary
The facility failed to provide a functioning call light system in resident bathrooms and bathing areas, as required by policy, for three residents. The policy mandates that each resident must have access to a call light at the bedside, toilet, and bathing area, with calls relayed directly to staff or a centralized location to ensure timely response. Staff are instructed to report any call light issues immediately and provide alternative solutions until repairs are made. However, multiple work orders for broken call lights remained unaddressed, and no manual call bells were provided in affected rooms. One resident, admitted with diagnoses including infectious gastroenteritis, congestive heart failure, and diarrhea, required assistance with activities of daily living (ADLs) due to limited mobility. This resident's call light was found detached from the wall, with no manual call bell available, making it difficult to summon staff when help was needed. Another resident, who was cognitively intact and dependent on staff for ADLs, reported that the call light in their shared room had not worked for four months, and no manual call bell was present. This resident also expressed concerns about staff responsiveness due to the ongoing issue. A third resident, also dependent on staff for ADLs and identified as a fall risk, was found in a room where both call lights were nonfunctional. Staff were unaware of the broken call lights until the time of observation and interview. The maintenance director acknowledged awareness of the issue and difficulties in obtaining replacement parts, while the administrator and DON were informed of the ongoing problems. Despite the facility's policy and the residents' needs, the lack of a working call system persisted, leaving residents without a reliable means to request assistance.