Failure to Maintain Functional Call System in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that resident call systems were functioning properly in bathrooms and bathing areas, as evidenced by the experience of one resident who reported that her call light was not answered on multiple occasions. The resident, who had multiple diagnoses including chronic respiratory failure, diabetes, dementia, and other serious conditions, stated that staff provided her with a handheld bell due to the malfunctioning call system. Medical record review and interviews confirmed that the resident required assistance with activities of daily living and had ongoing health concerns. Observation and interviews with facility staff, including the Administrator and Maintenance Director, revealed a known issue with the call system in double rooms with shared bathrooms. Specifically, if a metal lever or switch in the bathroom was left partially engaged, the call light above the resident's bed would illuminate but would not send a signal to the nurses' station or outside the room. Review of Resident Council meeting minutes also documented ongoing resident concerns about call light response. There was no facility policy specifically addressing call lights, though staff were expected to respond in a timely manner.