Failure to Maintain Effective Resident Call System Resulting in Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that an effective and functioning resident call system was accessible to all residents on the first floor. Specifically, the call light system did not provide an adequate audible or visual alert to staff when the call light was disconnected from the wall at the bedside. This deficiency was observed in multiple rooms, including the rooms of two residents, where disconnecting the call light resulted in only a barely audible beep at the nurses' station and no visual indicator above the rooms. Staff interviews confirmed that the call light system was not effectively notifying them when disconnected, and frequent manual checks were relied upon instead. One resident, who had end-stage heart failure, chronic kidney disease, hypertension, and was on hospice care, required substantial to maximal assistance for toileting and hygiene and was at high risk for falls. The resident was care planned for hourly checks and had a pad-style call light intervention to be kept within reach at all times. Despite these interventions, the resident was found deceased on the floor with the call light detached and unalarmed at the nurses' station. The resident had a history of multiple falls and was receiving scheduled and PRN laxatives for bowel management, with evidence of recent bowel incontinence at the time of the incident. Further investigation revealed that the facility did not have any policies or routine procedures in place to ensure the call system's audible and visual indicators remained operational. The DON and Administrator confirmed that the call lights were easy to pull out of the wall, that residents did so frequently, and that there was no system in place for regular testing or maintenance of the call light system. These failures resulted in all residents on the first floor being left without a reliable means of calling for assistance during emergencies.