Failure to Maintain Call Light System and Enforce Pager Use
Penalty
Summary
The facility failed to maintain its call light system in working order and did not adhere to the stipulations outlined in the state exception granted for the use of its wireless call light system. Observations, interviews, and record reviews revealed that the call light system was not consistently operational, and direct care staff were not carrying pagers as required by both facility policy and the state exception. The exception specifically required all direct care staff to carry pagers to compensate for the lack of corridor indicator lights and audible signals, but multiple staff members, including CNAs, LPNs, and CMTs, confirmed that pagers had not been used for several months and that the requirement was no longer enforced or monitored by administration. A resident with a history of renal failure, depression, heart failure, and bipolar disorder experienced a significant event when their call light failed to function during a time of need. The resident reported severe foot pain and attempted to use the call light system for assistance, but no staff responded until a hospice nurse arrived several hours later. The resident stated that this was not the first time the call light system had failed and that the issue had persisted for months, with only temporary fixes applied by staff and maintenance. The resident was unable to call out for help due to their condition, further highlighting the impact of the malfunctioning system. Interviews with staff and the maintenance director confirmed that there was no internal audit or monitoring system in place to ensure the call light system was functioning properly. The maintenance director acknowledged that the system was monitored by an outside agency, but no alerts were sent to the facility in the event of a malfunction. The administrator was aware of the stipulations in the exception but was not aware that staff were not carrying pagers. The lack of enforcement and monitoring of both the call light system and pager usage directly contributed to the deficiency, affecting the ability of residents to request and receive timely assistance.